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THE MEDICAL REPORT OF THE 
 RICE EXPEDITION TO BRAZIL 
 
 BY 
 
 W. T. COUNCILMAN, M.D. 
 
 AND 
 
 R. A. LAMBERT, M.D. 
 
 FROM THE SCHOOL OF TROPICAL MEDICINE 
 HARVARD UNIVERSITY 
 
 CAMBRIDGE 
 HARVARD UNIVERSITY PRESS 
 
 LONDON: HUMPHREY MILFORD 
 
 Oxford University Press 
 
 1918 
 
fittt 9i the i-'rcSiUoDi 
 
 AUG 7- 1918 
 
 COPYRIGHT, 1918 
 HARVARD UNIVERSITY PRESS 
 
TO 
 MRS. A. HAMILTON RICE 
 
 AS AN APPRECIATION OF HER ENDURANCE, 
 
 PATIENCE, FORTITUDE, AND CHEERFULNESS 
 
 THIS WORK IS RESPECTFULLY DEDICATED 
 
 BY THE AUTHORS 
 
INTRODUCTION 
 
 The expedition, primarily undertaken for geographical 
 research, was organized by Doctor A. Hamilton Rice, 
 and left New York on the steam yacht Alberta, Novem- 
 ber 16, 1916. The members of the expedition were 
 Doctor and Mrs. A. H. Rice, Mr. Howe, geologist, 
 Mr. Swanson, wireless operator, Mr. Cousens, engineer, 
 Mr. Church, cartographer, and the writers. Stops were 
 made on the way to and from Brazil at Barbados and at 
 Porto Rico. From Barbados we proceeded on the yacht 
 to Para, to Manaos, and to Iquitos in Peru, returning 
 from there to Manaos. At Manaos a river steamer was 
 taken to San Isabel on the Rio Negro, and from there 
 we proceeded to San Gabriel on a launch which was 
 constructed in New York for this purpose, and sent to 
 Manaos on a commercial steamer. 
 
 The main purpose of the expedition was the study of 
 the physical geography of the Casiquiare Canal (a 
 natural waterway between the Rio Negro and the Ori- 
 noco River), the branches of this, and the region. This 
 particular region has enjoyed an unenviable reputation 
 from the great numbers, the variety, and the rapacity 
 of the insects, and from the severe character of the 
 endemic diseases. It is also a region which is rarely 
 visited save by the rubber traders and about which 
 little is known. Owing to the unprecedented low water 
 in the Rio Negro it was not possible to go further up 
 than to San Gabriel, where we waited for three weeks 
 in daily expectation of a rise in the river. The river. 
 
vi INTRODUCTION 
 
 however, continued to fall, and reports from higher up 
 were that the canal was not passable even for a large 
 canoe. From San Gabriel the return to Manaos was 
 made on the launch, one of the party only (W. T. C.) 
 coming down the river from San Isabel on a steamer. 
 In the ascent of the Rio Negro the south bank, the usual 
 route, was followed, and the descent to Manaos, which 
 was made in the launch, was to a considerable extent 
 along the north bank, which is little known. Both going 
 and coming stops were made at the small towns and 
 villages, and at many of the rubber estates, and the 
 inhabitants were examined. The prolonged stay at San 
 Gabriel gave a good opportunity for the study of the 
 conditions of the region. From Manaos one of the 
 party (W. T. C.) made a trip on a river steamer through 
 the series of rivers, lakes, and streams on the south of 
 the Amazon between Manaos and the Madeira river. 
 In passing up the Amazon to Iquitos a number of stops 
 were made at the small towns along its banks. In Para, 
 Manaos, and Iquitos the hospitals were visited and the 
 cases in the wards were studied. All of the physicians 
 encountered were most kind, and all medical facilities 
 were freely placed at our disposal. This was in accord 
 with the hospitality shown us everywhere. 
 

 MEDICAL REPORT OF THE RICE 
 EXPEDITION TO BRAZIL 
 
MEDICAL REPORT OF THE RICE 
 EXPEDITION TO BRAZIL 
 
 The Amazon Valley 
 
 It is necessary before a consideration of the diseases 
 of this region to give some account of its physical char- 
 acteristics, for the two are closely interlinked. The land 
 of the Amazons, including the great valley and the lower 
 watershed, is in several respects the most remarkable 
 and interesting region on earth. It is the largest area 
 on earth which can be treated as a unit and in which 
 practically the same conditions prevail. There are 
 various estimates of its extent, ranging from 1,500,000 
 to 2,722,000 square miles, the difference depending 
 upon what are regarded as the limits of the region. The 
 region extends in the west to the Andes, to the high 
 table-lands of the Matto Grosso in the south, to the 
 high lands and the coastal range of mountains on the 
 east, broken only by a few hundred miles at the mouth 
 of the river, and to the mountains of Venezuela and 
 Guiana on the north. The valley itself is almost as flat 
 as the sea. There has been much difficulty in ascertain- 
 ing altitude owing to the influence of atmospheric con- 
 ditions on the barometer. The very careful estimates of 
 Rice made on this expedition give 83 feet at Manaos, 
 and 315 feet at Iquitos, 151 at San Isabel and 225 at San 
 Gabriel. The trade winds sweep across the valley from 
 east to west carrying, in great purple and white cumulus 
 clouds, masses of water vapor, which partly is preci- 
 pitated over the valley in passing, but the height of 
 
 3 
 
4 THE RICE EXPEDITION TO BRAZIL 
 
 discharge is reached on the slopes of the Andes, where 
 the clouds meet the cold air of the mountains.^ A glance 
 at a map shows great numbers of rivers coming from the 
 north and south, which flow into the Amazon, and 
 these become more numerous in the west as the Andes 
 are approached. The volume of water discharged is 
 
 ^ " The northeast trade winds commence to blow about the Tropic of 
 Cancer, and coming from the quarter thej^ do, they blow obliquelj^ across 
 the Atlantic. Thej' evaporate from the sea as they go; and, impinging at 
 right angles upon the South American shore-line that extends from Cape 
 St. Roque to Cabo La Vela, they carry into the interior the vapor that 
 forms the clouds that give the rain which supplies with water the Mag- 
 dalena, the Orinoco, and the northern tributaries of the Amazon. 
 
 The volume of water discharged by these rivers into the sea is expres- 
 sive of the quantity which those northeast trade winds take up from the 
 sea, carry in the clouds, and precipitate upon the water-shed that is drained 
 by these streams. They are but pipes and gutters which Nature has 
 placed under the eaves of the great water-shed that has the Andes for a 
 ridge-pole, the Caribbean sea and North Atlantic for a cistern. 
 
 The trade-wind region of the North Atlantic affords the water-surface 
 where the evaporation is carried on that supplies with rains, dews, and 
 moisture. New Granada, Venezuela, the three Guianas, and the Atlantic 
 slopes of Ecuador. 
 
 On the other hand, the southeast trade winds commence to blow about 
 the parallel of 30° or 35° south. They, too, come obliquely across the 
 Atlantic, and strike perpendicularly upon the South American coast-line 
 which extends from Cape St. Roque towards Cape Horn. They pass into 
 the interior with their whole load of moisture, every drop of which is 
 wrung from them before they cross the Andes. The quantity of moisture 
 which is taken up from the sea and rained down upon this wonderfully 
 fruitful country may be seen in what the La Plata and the Amazon dis- 
 charge back into the ocean. 
 
 Now, there is no tropical country in the world which has to windward, 
 and so exactly to windward of it, such an extent of ocean in the trade-wind 
 region. Consequently there is no inter-tropical country in the world that 
 is so finely watered as is this great Amazon country of South America. 
 
 Along the Atlantic coast of the LTnited States, along the coast of China, 
 and the east coast of New Holland, the land trends along with the direction 
 of the trade winds of those regions. These winds, with their moisture, 
 travel along parallel with the land. They do not blow perpendicularly 
 upon it, nor push their vapors right across it into the interior, as they do in 
 South America. The consequence is, none of those inter-tropical countries 
 can boast of streams and water-courses like those of South America." — 
 " The Amazon," and " The Atlantic Slopes of South America," by M. F. 
 Maury, LL.D., Lieutenant U. S. Navy. 
 
MEDICAL REPORT 5 
 
 enormous. Leaving out of consideration that of the 
 Para estuary which receives the Tocantins and several 
 smaller rivers, the discharge of the Amazon proper is 
 greater than that of the Mississippi and Nile combined, 
 the great flood converting the ocean into a fresh water 
 sea for one hundred and fifty miles from the coast. This 
 statement is based on estimates made of the outflow at 
 Obidos, where the river bed is constricted between high 
 terra firme to a width variously estimated at one and 
 one and a half miles. Wallace made his estimate of the 
 discharge, 750,000 cubic feet per second, by taking an 
 average depth of fifty feet, a width of one mile, and a 
 current of four miles an hour. Herndon, however, has 
 made soundings here, showing depths of one hundred 
 and fifty, one hundred and seventy, two hundred and 
 ten and two hundred and forty feet, and the great rivers, 
 Tapajos and Xingu, enter the Amazon stream below 
 Obidos. Wallace has also estimated the rainfall of the 
 valley and finds that the estimated rainfall 1,500,000 
 feet per second corresponds with the estimated discharge 
 estimating the evaporation at one-half the rainfall.^ 
 
 The color of the Amazon is a pale cloudy yellow; the 
 color is due to a finely divided silt which precipitates 
 slowly and imperfectly. Many of the tributary streams 
 have the same character, while others are clear and of 
 various shades of amber, and these are known as the 
 black water rivers, -the best type being the Rio Negro.^ 
 
 The height of the land along the river varies, being 
 much lower in certain places, and has received in relation 
 
 1 Estimates play a predominating part in all descriptions of the phj^sical 
 features of South America. 
 
 2 " Soon afterwards we discovered a river, on the left hand, with water 
 as black as ink, the force of wliich was so great that for more than twenty 
 leagues its waters flowed separately, without mingling with the Amazons 
 river." - — Orellana, 1539. 
 
6 
 
 THE RICE EXPEDITION TO BRAZIL 
 
 to its height above water certain designating names. 
 The entire low region subject to flood is known as the 
 flood plain, and this is divided into igapo and varzea. 
 The igapo, really a swamp forest, (Fig. 1) is the lowest 
 land, but a few feet above the mean level, and is subject 
 to overflow by the tides in the east and by slight rises in 
 the river. The principal area of the igapo is the flat 
 
 ►f 
 
 
 
 
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 A|,^ 
 
 
 
 JMflrf^^T 'Biiii6tH 
 
 &h im^^ 
 
 jb-^i^ > ^, 
 
 
 „:^aBf 
 
 ^^_ 
 
 m (-yKKSSuiUKI^L. vu 
 
 
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 Fig. 1. Igap6 on lower Amazon. 
 
 coastal region east of Obidos. It is a country of islands 
 separated by sluggish but often deep channels, of rivers 
 and of lakes, the whole unstable and constantly chang- 
 ing. The varzea is the higher land which is overflowed 
 only during the high floods. The terra firme is still 
 higher land, which is not subject to overflow. All of the 
 rivers in the valley have igapo and varzea on both sides 
 of them and extending a varying distance, broken here 
 and there by higher terra firme. The terra firme rep- 
 resents more than a difference in altitude, for it has a 
 clay or rock foundation, a sand surface and is stable. 
 
MEDICAL REPORT 7 
 
 The igapo and varzea are formed of alluvium; the land 
 constantly changing, disappearing in one place, forming 
 in another; large islands disappear in the floods, others 
 are formed, igapo becomes varzea and vice versa (Figs. 
 2 and 3). While on the way to Iquitos we saw a large 
 section of the bank covered with high forest fall into the 
 river and completely disappear. The best conception of 
 the condition is gained by regarding the entire flood 
 plain as a great lake which has been filled with sediment 
 until only the rivers remain. 
 
 The region is covered with forest, in extent the largest 
 forest in the world; the towns and the clearings in it 
 represent merely pin pricks. On the outskirts of the 
 valley there are great regions, known as campas, free 
 from forest, resembling the American prairies and cap- 
 able of pasturing immense herds of cattle. Wallace 
 states that from Tabatinga on the border of Peru a circle 
 can be drawn with a radius of eleven hundred miles, 
 all of which will be within the forest. Outside of this, 
 smaller circles with radii up to four hundred miles can 
 still be included. The varieties of trees and the density 
 of the forest vary somewhat in different regions, but the 
 general characteristics are the same. The trees are tall 
 and closely placed; the trunks generally smooth and 
 pale in color, giving off no branches until the forest roof, 
 eighty to a hundred feet above the ground, is reached. 
 Above this roof the domes of many of the higher trees 
 project. Between the tall trees there is another forest 
 of slender, shade-loving trees, and of others which await 
 an opening in the roof through which to get their heads 
 into the light. Vines are everywhere, trailing over the 
 ground, extending up the trunks of trees and as long 
 tightly stretched ropes descending from the trees to 
 the earth. Most of the latter are the aerial roots of 
 
8 THE RICE EXPEDITION TO BRAZIL 
 
 I"n;. ■i. \ AHZKA K)l{h_ST WITH HKill SIIAHI* HANK DTK TO liK« KNT <A\1NU 
 
 Fu;. .'J. \ AK7.KA WITH LOW HANK AND UKCKNT DKPOSITION. 
 
MEDICAL REPORT 9 
 
 parasitic plants which hve on the trees high up in the 
 light. The tangle of vines and trees is densest along the 
 banks of rivers where light comes from the sides as well 
 as from overhead and here the forest is impenetrable. 
 The forest yields many products, the most important 
 of which, commercially, is rubber. Many varieties of 
 trees produce a form of rubber but the best is obtained 
 from the Hevea Braziliensis hj making incisions in the 
 bark. Much of the timber of the forest is of great 
 beauty of color and grain and has come into some use in 
 cabinet work, but as yet the forest has been practically 
 untouched. Palms are found in all regions, but the 
 igapo is their home, and they are found here in many 
 varieties, some of them the largest and most beautiful 
 of the genus. They are among the most useful trees of 
 the forest; the fruit of many is of value as food, the 
 leaves are used for thatching, and fibres formed from 
 the leaves serve the purposes of flax. 
 
 There are seasonal variations in the rainfall forming 
 a long wet and long dry season, and between these a 
 short dry and short wet season. There is a general rise 
 in the rivers from March to June, with a slighter rise in 
 December. Notwithstanding the great number of 
 rivers and their depth, they are insufficient to carry off 
 the volume of the water which falls in the rainy season 
 and the entire region of igapo and varzea is flooded. 
 The height to which the water rises in the floods in dif- 
 ferent localities varies greatly and seems to upset the 
 laws of hydrostatics. This is due to many conditions, 
 the most important being the general flatness of the 
 region and the great tortuosity of the rivers. In the 
 eastern end the flood rains come two months earlier 
 than in the west; and in the northern part, which is 
 drained chiefly by the Rio Negro, the rains are inter- 
 
10 
 
 THE RICE EXPEDITION TO BRAZIL 
 
 mediate. The rise in some places is enormous. At 
 Manaos the maximal rise is a hundred feet and the usual 
 forty to fifty. The valley becomes a vast sea and canoes 
 pass through the forest. The inhabitants of the low 
 lands take to boats or withdraw to the terra firme and 
 thousands of cattle are drowned each year (Fig. 4) . The 
 flood is the time of scarcity owing chiefly to the wider 
 distribution of the fish which renders their capture diffi- 
 
 Jan. Feb. March April May June July Aug. Sept. Oct. Nov. Dee. Jan. Feb. 
 
 . = 1914 
 - = 191.5 
 
 1914, Total Rainfall 1821 mm. = 73 inches 
 
 1915, " " 2266 mm. = 91 inches 
 
 Fig. 3a. Rainfall at Manaos, 1914-1915. 
 
 cult, and the deprivation of the land. Mosquitoes and 
 fever are more common at the end of the rainy season. 
 Even during the wet season the rain is not continu- 
 ous, it comes usually in the afternoon and is often of 
 great intensity. The rainfall at Manaos for 1915 was 
 ninety-one inches, and seventy-three inches for 1914. 
 
 The prevailing wind is in the direction of the trades, 
 from east to west, and there is in general little wind 
 movement. Storms are rare, of short duration, and local 
 in their effects. The forest rarely shows tracks of storm, 
 
MEDICAL REPORT 11 
 
 and for the most part in the early morning and evening 
 the waters show as perfect a mirror as a mountain lake. 
 Throughout this vast region communication is by 
 water only; the rivers and tributary streams are so 
 numerous that a large area is accessible. There are also 
 many communicating streams between the rivers and 
 lakes, open to steamer navigation. Extending from the 
 rivers there are everywhere igarapes or canoe paths, 
 which pass for long distances into the land. The extent 
 
 Fig. 4. Terra firme. A sitio or plantation on the Autaz River. 
 
 of these waterways may be seen from the map (Fig. 5), 
 which represents a small region above Monte Alegre; 
 and the region of the Autaz river south of the Amazon 
 through which one of us passed is very similar. There 
 are no railroads in the region and no roads to be tra- 
 versed by horse or vehicle save in the immediate vicinity 
 of the larger cities and towns. Shallow draught 
 steamers, usually propelled by a stern wheel and using 
 wood for fuel, make trips to the head of navigation on 
 the various rivers, the trip often taking several weeks. 
 Most of these steamers are owned by English companies 
 
12 THE RICE EXPEDITION TO BRAZIL 
 
 and have headquarters in Para, Manaos, and in Iquitos. 
 In addition to the steamers, launches ply on the smaller 
 streams, using kerosene for fuel. The steamers we have 
 seen were comfortable, the food good and more than 
 abundant. The region between the rivers is for the most 
 part unknown and inaccessible. There have been 
 hazardous explorations in certain regions, and paths 
 made by Indians and rubber-gatherers extend inward 
 for short distances only. 
 
 The valley of the Amazon is the most unchanged and 
 unchanging great region on earth. It presents the same 
 features as it did in 1539 when Orellana, deserting his 
 commander, first came down the great river from the 
 Kingdom of Quito, the Ecuador of today, and the descrip- 
 tion of the life of the Indians given by Acuna a hundred 
 years later holds with few exceptions for today. 
 
 It is a solitary region and the longing of the poet " for 
 a lodge in some vast wilderness " could be easily grati- 
 fied. The usual estimate of the population is one to the 
 square mile, but there is no accurate knowledge of the 
 population, nor whether it is increasing or diminishing. 
 Judging from Acuiia's narrative in which he describes 
 the villages along the Amazon as forming an almost con- 
 tinuous line, it is diminishing. There has been some 
 increase in the population of such cities as Para, Manaos, 
 and Iquitos, but the population of the smaller towns, 
 especially along the Rio Negro, is said by the best in- 
 formed to be diminishing, and there is further evidence 
 of this in the ruins of houses and churches. It is possible 
 to travel in a steamer for an entire day without seeing a 
 human habitation. The population is on the highway 
 of the water courses. Here are the towns which with the 
 exception of the cities of Para, Manaos, and Iquitos, are 
 of small size, rarely exceeding a thousand inhabitants. 
 
14 
 
 THE RICE EXPEDITION TO BRAZIL 
 
 There is some confusion in the statements regarding 
 population in that the town includes an entire district 
 of many square miles. There are sparse villages com- 
 posed of palm thatched huts and scattered single 
 huts (Fig. 6) . Many of the towns and villages as seen 
 from the river are exceedingly picturesque, situated as 
 they generally are on high land with areas of grazing 
 land about them, on which a number of forest trees of 
 
 Fig. 6. San Gabriel on the upper Rio Negro. This is at the first 
 rapids and was formerly a trading station of importance and 
 
 there ARE RUINS OF A FORT WITH SEVERAL ANCIENT GUNS. 
 
 great height and size have been allowed to remain when 
 the land was cleared. There are many palms, single and 
 in groups, and in the gardens around the houses are the 
 broad leafed banana, pawpaw, bread fruit, and citrous 
 trees. 
 
 Indians compose the bulk of the population and 
 although divided into many tribes have a more or less 
 interrelated language and common physical character- 
 istics. They are generally short and heavily built, the 
 
MEDICAL REPORT 
 
 15 
 
 Fig. 7. Plantation Indians. Attached to a rubber plantation on the 
 
 Rio Negro. 
 
 Fig. 8. 
 
 Forest Indians of the Macu tribe. This is a low-caste ensl.\ved 
 
 TRIBE ON the RiO NeGRO. 
 
16 THE RICE EXPEDITION TO BRAZIL 
 
 chest large and muscular, the arms, owing to their being 
 a canoe people, more developed than the legs (Figs. 7 
 and 8). There is, however, much variation in the dif- 
 ferent tribes. The color is rather paler than that of the 
 North American Indians, No. 4 of Brocas scale, the 
 cheek bones not so high and prominent, the eye slits 
 narrow and the whole cast of countenance is more of 
 the Asiatic than the North American type. The hair 
 of the male is abundant, coarse, straight, and black, 
 lacking on the face and body. The hair of the female 
 is abundant and much finer. Depilation of the body is 
 practiced by both sexes. ^ 
 
 The Indians in all accessible regions are practically 
 enslaved by the rubber merchants,^ who have obtained 
 from the government concessions of the land. They 
 have become increasingly dependent, their agriculture 
 and arts are being lost, and they receive for their labor 
 rum, sewing machines, music boxes, and other useless 
 products of civilization. They are in general a non-war- 
 like, patient, and docile race, not lacking in intelligence, 
 and these very qualities render their exploitation the 
 more easy. In places remote from civilization dreadful 
 atrocities have been perpetrated, dwellings burned, men 
 killed, women and children carried off. The remote 
 Indians, in regions where the toils of the rubber exploita- 
 tion have not extended, live in maloccas, or community 
 houses, hidden in the depths of the forest, and reached 
 by concealed paths which extend from a river or a small 
 stream navigable only for a canoe. The maloccas are 
 often of great size, sheltering as many as two hundred 
 
 ^ It is quite striking how rarely one sees baldness in either whites or 
 Indians in this part of Brazil, with the exception of the foreigners. 
 
 ^ The Indians represented in Fig. 8 are women from an inferior tribe 
 of forest Indians who with their driver were on their way to the rubber 
 regions. 
 
MEDICAL REPORT 17 
 
 inmates and are cleverly constructed of beams and poles 
 lashed together with vines and covered with palm 
 thatch. Within the common dwelling each family has 
 its own fireside and independent life, the social organiza- 
 tion resembhng the "long house" of the Iroquois. There 
 are cleared plantations in the vicinity of the malocca, 
 the care and cultivation of which is entrusted to the 
 women, while the men prepare the ground by cutting 
 down and burning the forest, hunt, fish, and rest from 
 their labor. Certain of the customs are also to the 
 advantage of the male, as when a woman gives birth to 
 a child the father goes through a period of rest in his 
 hammock and receives delicacies and congratulations. 
 Inter-tribal wars are common and have been one of the 
 means of depleting their numbers. 
 
 Apart from the Indians the population is a hetero- 
 geneous mixture. The Brazilian population, originally 
 Portuguese, has interbred freely with both negroes and 
 Indians, the Indian half-breed mameluco being as a 
 rule superior to the mulatto. There is a steady immi- 
 gration of Portuguese who form an industrious, hard 
 working population, and do most of the work. The 
 population in the cities is extraordinarily varied, for the 
 wealth coming from the rubber industry has attracted 
 immigrants from the entire world and every nationality 
 is represented among the prominent rubber merchants. 
 As in other places, certain trades fall into the hands of 
 different nationalities; the sale of dry goods by peddling 
 is in the hands of the Armenians, and the very extended 
 trade of prostitution is chiefly conducted by the Poles. 
 Few of the whites, except those of the lowest class, 
 engage in the actual collection of rubber or other forest 
 products. On the land the whites generally live in vil- 
 lages or on large estates. The houses of these estates 
 
18 THE RICE EXPEDITION TO BRAZIL 
 
 are situated on prominent points of the rivers and sur- 
 rounded by offices and farm buildings; life in many of 
 these is on a feudal scale and a wide and generous 
 hospitality is dispensed. 
 
 In addition to rubber the region produces gutta 
 percha, sarsaparilla, tobacco, sugar, cacao, mandioca, 
 piassaba fibre, nuts, and a variety of forest products, 
 among them many valuable drugs. The chief exports, 
 are rubber, nuts, and sarsaparilla. The great wealth 
 of the region, which has hardly been touched, lies in 
 the timber, and as a source of natural wealth this can 
 hardly be destroyed. There are many difficulties which 
 lie in the way of its exploitation, the chief of these being 
 the great variety of the growth. All of the wood has 
 value as timber but the character differs so greatly that 
 the unsorted lumber could not be used for a common 
 purpose not even for the production of wood pulp. 
 Doubtless, however, the time is approaching when the 
 demand for lumber, with the rapidly decreasing supply, 
 will compel the world to draw upon this seemingly 
 inexhaustible source. 
 
 Life in the region is primitive in the extreme. Almost 
 every house has a small plantation of mandioca {manihot 
 utilissima) which forms the staple food. The roots of 
 this, after being thoroughly washed and soaked, are 
 grated on a rude grater of wood into which small sharp 
 pebbles are inset, the mass of pulp is again steeped in 
 water and the juice, which contains a poisonous prin- 
 ciple, expressed. The resultant material is then dried 
 or baked in a rude oven and crushed into grains of vary- 
 ing fineness. There are several varieties of the plant 
 and the products differ correspondingly. It is eaten 
 mixed with other foods or stirred in water to a thin 
 gruel. In certain regions maize is used in the same ways 
 
MEDICAL REPORT 19 
 
 as by the North American Indians. No flour is made in 
 the region, all of this or its products being imported. 
 Coffee and cacao, the latter in large amount, are also 
 produced. Save in the cities and on the large estates 
 meat enters but little into the food. Fish are abundant 
 in the rivers and of excellent quality, turtles are numer- 
 ous and with their eggs, which are collected in large 
 quantities, constitute one of the staple foods. Although 
 great numbers of cattle are raised on some of the rivers, 
 milk and dairy products except in the form of cheese, 
 are rarely seen beyond the plantations. The principal 
 vegetables outside of the universal mandioca are yams, 
 beans, sugar cane, maize, and rice. Cabbage, which 
 grows rapidly and never forms heads, melons, small and 
 inferior, peppers in great variety of size, form, and pun- 
 gency, are also raised in the gardens. Pigs are found 
 almost in a wild state about the villages and houses; 
 they live on the offal, the wild fruit, and nuts and receive 
 no care save an occasional scattering of corn. Chickens 
 also form a part of the domestic animals. Nearly every 
 house has about it a few fruit trees; bananas, pine- 
 apples, oranges, mangoes, pawpaw, alligator pears, and 
 bread fruit are the most common; the pupunha, or peach 
 palm, the fruit of which is delicious and nutritive, the 
 cucura, whose fruit is borne in clusters and resembles 
 in flavor the black Hamburg grape, are less common. 
 Cattle are not found save about the large plantations 
 and villages where there are areas of grazing lands. 
 With a very slight expenditure of toil an abundance of 
 food of excellent quality is produced. 
 
 A sort of beer is made by the fermentation of both the 
 sugar-cane juice, maize, and mandioca, but the general 
 intoxicant all over the country is cachaca or rum, which 
 is made and used everywhere. The rum is white, of 
 
20 THE RICE EXPEDITION TO BRAZIL 
 
 inferior quality and is used generally fresh from the still. 
 There is no government tax upon the product nor regu- 
 lation of its sale. It has been the principal means by 
 which the degradation of the Indians has been brought 
 about and to its unrestricted use the general low stage 
 of development of the entire region is to be largely 
 attributed. In addition to these alcoholic drinks coca 
 and guarana, the latter containing a large amount of 
 caffein, are used as stimulants. 
 
 In spite of the enormous tree growth covering the 
 land, clearing is not very difficult and owing to the rich- 
 ness of the soil and the combination of this with heat 
 and moisture, growth of all sorts is so luxuriant that 
 a small area will produce a large amount of food. In 
 clearing, all except the largest trees are felled and the 
 immense mass of tangle which results is burned, taking 
 days or weeks, and although the smaller trunks and 
 vines are consumed the great fallen trunks remain until 
 the more thorough work of fungi and ants causes their 
 disappearance. The thickness of the bark of the great 
 trees which are left standing protects them from the 
 effect of the fire. These noble trees in a pasture of 
 closely cropped fine thick grass, at all times a vivid 
 green, with fine cattle standing in the grateful shade 
 given by the crown of foliage often a hundred feet above, 
 and with towering palms, single or in groups, which 
 always seem to seek a situation with an eye to the 
 picturesque, form a sight never to be forgotten. 
 
 Mammalian life is not abundant in the forest save in 
 areas away from the rivers, and even edible birds are 
 comparatively rare; though geese, ducks, and snipe are 
 abundant along the upper waters of some of the rivers. 
 With the exception of the herons, the interesting non- 
 edible ciganas, the parrots and macaws, and the two or 
 
MEDICAL REPORT 21 
 
 three common varieties of small birds, such as parroqiiets 
 and troupials,^ all of which are seen along the rivers or in 
 clearings, the traveller rarely sees a bird. In the forest 
 they may be present but they live in the high roof in- 
 visible to the untrained eye. Of edible mammals there 
 are tapirs, wild hogs or peccaries, monkeys, small deer, 
 armadillos, and a few smaller animals of the rodent 
 family. Starvation awaits every individual who at- 
 tempts to live from the products of the wilderness, if 
 away from the rivers. Much of the life is inimical or 
 certainly unfriendly to man. Of dangerous beasts the 
 jaguar only deserves mention, and though there are 
 records of an unprovoked attack on man, the cases are 
 so rare as to be negligible. There are very few danger- 
 ous and poisonous serpents. The boa constrictor is very 
 rare, but has been known to attack man; and of the 
 poisonous reptiles the most common are the jacaraca, 
 the rattlesnake, and the coral snake, all more common 
 in the uplands than in the river forests. 
 
 The Insects 
 
 It is when we come to the insects that the real ene- 
 mies of man are encountered. They are the masters of 
 the wilderness and they seek to extend their dominion 
 over all w^ho intrude. The most ubiquitous are tlie ants. 
 No region, no home is free from them, whether in city 
 or country, in forest or clearing. So far as can be ascer- 
 tained, though troublesome and unpleasant, tliey con- 
 vey no diseases. One of them, gigantic in size, an inch or 
 more in length, the Tucandera or conga, is found chiefly 
 
 ^ The troupials give an interesting example of the use of a protective 
 environment. The colonies of their long dependent nests are placed on 
 trees which also contain the homes of the most venomous wasps of the 
 region thus ensuring protection of the eggs from the monkeys. 
 
22 THE RICE EXPEDITION TO BRAZIL 
 
 in the forest, produces great pain and prostration by 
 its sting,^ and instances have been known of a number 
 of bites resulting fatally. These ants never invade the 
 houses. There is a small variety, well named "fire ant" 
 from the effect of its sting, which has sometimes invaded 
 villages and driven the inhabitants away. There are 
 also armies of foraging ants which destroy everything 
 which comes in their way. The most interesting are the 
 Saiiba or leaf -cutting ants which carry sections of leaves 
 to their nests along narrow smooth paths which they 
 form in the forest and fields. This material, after under- 
 going a preparation by chewing, provides a soil on which 
 a fungus, which serves them for food, is grown. They 
 select only certain trees for their depredations and are 
 particularly fond of trees foreign to the region and which 
 are cultivated, such as the cacao tree. The planter must 
 wage a continuous warfare against them and they often 
 show great ingenuity and perseverance in circumventing 
 man's efforts. Nearly every flower which blooms in the 
 forest contains ants which seek the nectar and some even 
 have entered into neighborly relations with plants and 
 are of mutual assistance. 
 
 ^ Spruce, vol. i, says of the Tucandera ants: "It was about 2.00 p.m. 
 when I was stung and I experienced no alleviation of the pain until 5.00. 
 During all this time my sufferings were indescribable, I can only liken the 
 pain to that of a hundred thousand nettle stings. My feet, and sometimes 
 my hands, trembled as though I had the palsy, and for some time the per- 
 spiration ran down my face from the pain. With difficulty I repressed a 
 strong inclination to vomit. I took a dose of laudanum at four and I think 
 this did more than anything to lull the pain. I had been stung on the two 
 big toes, but the stings which caused me most suffering were four close 
 together among the fine veins below the left ankle. When the pain of all 
 the others had subsided this continued to torment me and pains shot from 
 it all over the forefoot and up the leg, in spite of the bandages. The pain 
 returned with great force at nine o'clock, and at midnight, and each time 
 caused me an hour of acute suffering. The next morning there was 
 numbness and the inflammation continued for thirty hours." 
 
MEDICAL REPORT 
 
 23 
 
 They excavate long tunnels in the earth, which extend 
 with communications for hundreds of feet, they throw 
 up long mounds of earth several feet in height, they form 
 great nests high up in trees with covered galleries leading 
 to them, or an entire 
 tree trunk or house 
 side may be covered 
 with shaggy masses of 
 material which form 
 their home (Fig. 9). 
 Many species are 
 winged and form their 
 nests high up in trees 
 without communica- 
 tion with the earth. 
 Their sting resembles 
 the thrust of a red 
 hot needle into the 
 skin and though pain- 
 ful for the moment 
 leaves no unpleasant 
 after-effect. The skin 
 is blanched over a 
 small area immedi- 
 ately around the sting 
 and a firm induration 
 forms which shortly 
 passes away. It is possible that in very tender skins 
 vesicles may be formed by the exudate. In a house 
 on the Autaz river small vesicles and superficial ero- 
 sions were seen on the bare feet and legs of a child of 
 four years, which the father said were caused by the 
 stings of small brown ants, numbers of which were seen 
 running about the floor. None of the other members 
 
 Fig. 9. Tree trunk covered with the 
 
 SHAGGY masses OF ANTS' NESTS. 
 
M THE RICE EXPEDITION TO BRAZIL 
 
 of the family were so affected, although frequently 
 stung. 
 
 There are also legions of wasps, many of them of great 
 size and extremely venomous, who construct nests of 
 complicated design, but who fortunately have as yet 
 not learned to prey upon man, and with care can be 
 avoided. 
 
 All travellers in the region regard the pium, a small 
 biting fly, as a most troublesome insect. These are not 
 more than 2-3 mm. in length and 1/2 mm. in breadth, 
 the underside of the body is pale, the back black with a 
 small glistening point between the wings which are not 
 closely folded. The insect is extraordinarily active and 
 its destruction or capture not easy to attain. It alights, 
 runs around quickly until it finds a suitable spot, then 
 quickly bites and fills with blood, and only when in the 
 act of sucking is capture possible. A hard swelling, 
 5 mm. in diameter and 2 mm. in height, is produced and 
 in the centre of this is a perfectly round spot of hemor- 
 rhage 1/2 mm. in diameter. The itching is intense and 
 when the bites are numerous there may be considerable 
 diffuse oedema, due probably to the combination be- 
 tween bites and scratching. Protection can be attained 
 only by close meshed head nets and gloves; citronella 
 oil is efficacious for a time but must be frequently 
 renewed and is itself irritating to some skins. The 
 piums are not widely distributed. The head waters of 
 the black water rivers are favorite localities and the Rio 
 Negro and Casiquiare Canal have enjoyed an unpleas- 
 ant notoriety in this regard. They are confined to the 
 banks of the rivers and are never seen in the adjoining 
 forest. They were very numerous and troublesome 
 when we were camped at Camanaos, just below the 
 rapids of San Gabriel, and it was a great relief to pass 
 
MEDICAL REPORT 25 
 
 from the heat and glare of the sand })ar into the cool 
 twihght of the forest, where the only insects were the 
 ants. The areas on the rivers most favored by the 
 piums are shores of sand bars and rocks with swift cur- 
 rent; they may be in great numbers in one locality and 
 absent in another, although the same conditions may be 
 present. There is no acquired immunity to the effect of 
 their bites, natives and Indians suffering equally with 
 strangers. There is a very general belief that the irrita- 
 tion following the bite may be lessened by puncturing 
 the small spot of hemorrhage and squeezing out the 
 blood which lies in a small cavity in the corium, but like 
 many therapeutic procedures it does not prove effective. 
 The pium is a day insect, arising promptly with the 
 sun and most active in the early morning after the repose 
 of the night. There is a very general belief that the 
 very common ulcers seen in the region are produced by 
 them, but in the absence of experimental evidence, this 
 may be questioned. We found no typical Leishmania 
 ulcers in the natives of the regions where the piums 
 were most abundant. At San Isabel the storekeeper was 
 so severely bitten that the bare feet and ankles looked 
 as though black pepper had been sprinkled upon the 
 skin. There was also some diffuse oedema, vesicle for- 
 mation, suppuration and superficial ulceration, but the 
 condition bore no resemblance to the Leishmania ulcer, 
 and responded readily to cleanliness and simple treat- 
 ment. The habit of stockings would be a valuable 
 innovation where the piums abound. 
 
 More tormenting even than the piums are the 
 micuims.^ These are so small as to be just visible to 
 
 1 This insect, whose Ufe history is known not at all or imperfectly, is a 
 larval form of a species of Trombididea. It has received different names in 
 the various places where found, and the name here used is probably a per- 
 
26 THE RICE EXPEDITION TO BRAZIL 
 
 the naked eye when on a surface of contrasting color. 
 They are a bright orange in color and when collected on 
 a white stocking this looks as though covered with red 
 pepper. They move with such rapidity over the skin 
 that it is difficult to keep one within the field of a lens, 
 and having selected a point they quickly penetrate 
 within the epidermis by a boring motion, the insect con- 
 stantly turning. No irritation is felt at the time, but 
 shortly great indurated wheals several centimeters in 
 diameter are formed, often with a small vesicle in the 
 centre, and the itching is intense. No other experience 
 can be compared with it, and it seemed impossible that 
 an insect so small could have such an effect. The insect 
 could frequently be recovered just within the epidermis 
 in the centre of the wheal, but there was no evidence 
 that ova were deposited nor did they seem to undergo 
 here any further metamorphosis. They are very gen- 
 erally distributed throughout the region, chiefly in the 
 pastures, and are much worse in the dry than in the wet 
 season. They attack the cattle who do not seem to be at 
 all bothered by them, and it seems probable that man is 
 only occasionally a prey and the peculiarly virulent 
 character of their poison is not really meant for man but 
 to reach through the far thicker epidermis of the cattle 
 who may have some additional protection in a partial 
 acquired immunity. In man there seems to be consider- 
 able individual variation in susceptibility to their effects. 
 The two individuals of our party who suffered most 
 were blonds, but at the same time these were most ex- 
 posed, one by his work of erecting stations for wireless 
 operation and the other from his habit of wandering 
 
 version of Mouqui, by which it is known in Peru. It is soft-bodied, with 
 six legs provided with claws and has a powerful hypostoma which it drives 
 into the skin. 
 
MEDICAL REPORT 27 
 
 over the fields to satisfy curiosity. They are much more 
 numerous in certain places than in others, and in the 
 older pastures rather than in the newly acquired. At 
 one large sitio where we spent several days it was neces- 
 sary to cut paths in the turf, leading from the house to 
 the various farm buildings, and the family was anxious 
 to sell the property and move away on account of them. 
 There is no protection against them, for they can easily 
 find their way to the interior through the openings of 
 clothing or even pass directly through it.^ The areas 
 of skin most attacked were the waist region, the but- 
 tocks, and the thighs, they seeming to select those parts 
 least susceptible to scrutiny. They can be partly 
 avoided by removing all the clothing when coming from 
 a walk and washing the body in strong rum, which kills 
 the insects in contact with it. We found that the best 
 means of allaying the intolerable itching was an appli- 
 cation of corrosive sublimate, 1-1000. 
 
 Of much less importance than these two main pests 
 are the meruim, a tiny fly much resembling the gnat of 
 Canadian rivers, which bites but leaves no effect, and the 
 matuca which bites fearlessly and fiercely both animals 
 and man, but which is not poisonous. Scorpions and 
 centipedes are numerous in some places, but we did not 
 encounter them. Spiders are numerous but did not 
 seem to be harmful. 
 
 There are some compensations. The ordinary house 
 fly is absent, nor do carrion flies seem to be present. 
 During our residence in San Gabriel swarms of small 
 black flies were attracted by sugar spilled on the floor, 
 but they were not troublesome, and like dinner guests 
 
 ^ High boots give no protection, for they quickly pass beyond the tops 
 of these. It is not improbable that some measure of protection might be 
 gained by a band of some sticky material around the boot just as trees are 
 protected against the ascent of gypsy moth caterpillars by such a band. 
 
28 THE RICE EXPEDITION TO BRAZIL 
 
 disappeared after the feast. All conditions seemed to 
 be present which would favor the life of the house fly 
 and it seemed to us that probably the reason for their 
 absence lay in the destruction of their larvae by ants. 
 So far as I know, however, no proof of this has been 
 shown. There are no privies in the region save in the 
 cities, but about the houses and villages there is little 
 or no evidence of soil pollution, all faeces being removed 
 by the ants in a few hours. ^ In the pastures also the 
 large faecal masses from the cattle remain but a short 
 time and the small grass clumps which in our pastures 
 denote past deposits are not seen. On the river banks 
 the cattle often lie in the warm sand at night, and here 
 where ants are absent the faeces remain until they dry 
 up. Although dead animals must be not uncommon, 
 there is no smell of carrion, for the buzzards and ants 
 quickly care for a carcass. There are no flies in the 
 pastures to bother the cattle, which to some extent ac- 
 counts for their good appearance and apparent content- 
 ment. The matuca, which does bite them, is confined 
 to the river shores. We have never seen mosquitoes 
 about them, though possibly as the mosquito here is a 
 nocturnal insect they may bite them at night. 
 
 It is interesting in placing insects in the order of 
 importance of their immediately unpleasant effects that 
 the mosquito should come last. The yacht was thor- 
 oughly screened, but on the long voyage up the Amazon 
 and return, during a great part of which both luncheon 
 and dinner were served on the open deck, they were 
 practically absent save on one or two occasions on the 
 upper river when we were at anchor close to the bank. 
 
 ^ The rarity of typhoid fever in the cities and its practical absence in 
 the country may also be due to the action of the ants as general scav- 
 engers. However, even if this be true, it is a large price to pay for 
 immunity. 
 
MEDICAL REPORT 29 
 
 In the cities we never saw them during the day but in 
 the hotel at Manaos I was several times bitten at night, 
 though under a mosquito bar. We have many times 
 been along the river shores in swampy land, partly over- 
 flowed, on shallow lakes, in short in many places where 
 similar conditions with us would have made such excur- 
 sions martyrdoms, without seeing, hearing or feeling a 
 mosquito. On the river boat which conveyed us from 
 Manaos to San Isabel we ate on the open deck, sat in the 
 evening on the deck, and slept in cabins without nets 
 and were not troubled. The boat, however, had been 
 thoroughly renovated and cleaned before leaving 
 Manaos. At San Isabel, although the other pests were 
 in full force, mosquitoes were not felt, although in 
 walking through the grass in the evening a few were 
 seen rising, and embryos were found in the water col- 
 lected in the bottom of an old canoe. This is at variance 
 with the ideas held and with the reports of travellers, 
 and is to a certain extent due to the period of the year 
 in which we were in the country. The relation of the 
 mosquitoes to the river travel, and to malaria will be 
 taken up elsewhere. 
 
 The Smaller Towns on the Amazon 
 
 High up on the Amazon above the Rio Negro there 
 are a number of small towns which we did not visit and 
 which are inferior in size and importance to those lower 
 dow^n. These towns, such as Tabatinga, Teffe, Fonta- 
 boa, Coary, are rarely visited by strangers and are 
 known from the early explorers who spent some time in 
 each of them. They are usually situated on high ground 
 on the bank of the river where there is an entering 
 affluent. They are the headquarters of the trade of the 
 region and as far as can be learned they present about 
 
30 THE RICE EXPEDITION TO BRAZIL 
 
 the same conditions as far as health is concerned as the 
 lower towns. 
 
 The general impression given by these Amazonian 
 towns is that they are comparatively healthy and have 
 in them the conditions which might give a pleasant life. 
 They have malaria but this does not seem to be a grave 
 form, certainly not hke the type we saw on the lower 
 Rio Negro. All of the accounts given of the Amazon 
 bear this out. The grave forms of fever are found not 
 here but high up on the tributary rivers. Of course such 
 cursory visits as ours could determine very little of 
 health conditions; there are no vital statistics of the 
 region, and if there were they would be unreliable. The 
 appearance of the people has some value, and from this 
 we should say that the region is fairly healthy, and the 
 conditions for existence easy. Certain diseases common 
 with us seem to be rare. We rarely saw a tumor, or 
 any cases evidently tuberculous, nor were there super- 
 ficial evidences of uncinariasis in high degree anaemias. 
 Of the prevalence of insect plagues we could not judge 
 for our stay was too brief, certainly we were not troubled 
 with mosquitoes or other insects. The shore conditions 
 along the Amazon river are not favorable for piums, 
 and several members of the party who made at Monte 
 Alegre and Santarem long excursions into the country 
 did not acquire micuims, but these, however, are pretty 
 generally distributed throughout the valley. There is 
 almost an utter lack of physicians, in some of the towns 
 there are none and of course none in the country. 
 
 The Towns of the Lower Amazon 
 
 Monte Alegre (delectable mountain), the name being 
 derived from the nearby low mountains which are a 
 continuation from the mountains of Guiana, was the 
 
MEDICAL REPORT 31 
 
 first of the Amazonian towns visited after leaving Para. 
 It is situated not on the Amazon directly, but on the 
 bank of a smaller river eight miles from its mouth. A 
 steep hillside three hundred feet in height, rising to a 
 broad plateau, divides the town into an upper and lower 
 part. The lower town lies along the river and consists 
 of a long street facing this and several short streets at 
 right angles. The upper town consists of a large open 
 square with the church and a number of houses on its 
 sides, all the houses small and of inferior construc- 
 tion. There are springs high up on the hillside, the 
 water from which is conducted into the town. The 
 country back of the town is high campo and is given 
 over to cattle raising and farming interests. There 
 'was the unusual spectacle of horsemen riding along 
 the streets. 
 
 The day of our arrival was a holiday and there w^ere 
 a large number of people in the town. Specimens of 
 blood were taken from twenty people. Eighty per cent 
 of those examined gave a history of malaria and all but 
 two had been well treated by a pharmacist with injec- 
 tions of quinine hydro bromate. Unfortunately we did 
 not examine for enlarged spleens, but we did not notice 
 any children with prominent abdomens, so common a 
 sight on the Rio Negro, nor did any of the people com- 
 plain of this trouble. The people were healthy looking 
 in spite of the fact that so many gave a malarial history; 
 for example, in a group of fifteen who were questioned 
 but whose blood was not examined, twelve gave a his- 
 tory of malaria (Fig. 10). The pharmacist said that 
 malaria was very prevalent, especially in late summer, 
 August, September, October, and November; there w^as 
 less in the winter or wet season, although mosquitoes are 
 worse at that time. Severe and fatal forms of malaria 
 
32 
 
 THE RICE EXPEDITION TO BRAZIL 
 
 were occasionally met with but quinine usually effected 
 a cure. We learned that diseases other than malaria 
 were rare and we saw none save a man with keratitis, 
 probably due to syphilis. The infant mortality was said 
 to be high. We found a number of persons who spoke 
 
 Fig. 10. View of inhabitants of Monte Alegre. The inn-keeper 
 IN the foreground, the wrestler in doorway. 
 
 English and who acted as interpreters, among them 
 a very stalwart Syrian who had come down from 
 Manaos for a brief holiday and who said he was the 
 first among wrestlers of the second class. There is no 
 hospital. Tertian parasites were found in two of the 
 cases examined. 
 
 Obidos 
 
 This is a town situated on the high bank of the Ama- 
 zon about five hundred miles from Para ; the population 
 three to five thousand. The situation is very pictures- 
 que, the tile roofs of the houses and the church standing 
 
MEDICAL REPORT 33 
 
 out amid a forest of palms and other trees. The narrow- 
 est part of the river is here, the greatest depth and the 
 most rapid current. The yacht anchored in twenty -five 
 fathom of water, three hundred feet from the bank. We 
 first called upon M. Paul Le Cointe, a French gentleman 
 who had married a Brazilian wife and who had large 
 plantations on the river. He is a naturalist, well known 
 for his contributions, a collector of objects pertaining 
 to the anthropology and natural history of the region, 
 and has received the medal of the Legion of Honor. He 
 has a large house and a beautiful garden, in which in 
 addition to plants peculiarly tropical are many roses and 
 our ordinary perennials and annuals. All these familiar 
 flowers were inferior to the same in our gardens. It was 
 Sunday and we probably saw most of the population on 
 the streets, in the cathedral and about the football 
 ground in front of the cathedral, where a ball game was 
 in progress. The people generally looked healthy and 
 well nourished. Six blood examinations were made, one 
 of them positive, the organisms young forms of tertian. 
 
 Itacoatiari 
 
 This town, the old name Serpa (Fig. 11), was visited 
 later on the trip to the Autaz. It is situated on high 
 ground on the north bank of the Amazon, almost oppo- 
 site the Madeira river and it was supposed that it would 
 have a large trade in connection with the Madeira and 
 Marmore railroad. It was formerly a rival of Manaos 
 but has declined in population and in importance. It is 
 a small and beautiful town of about two hundred houses 
 and back of it is a fine agricultural country which pro- 
 duces corn, cattle, tobacco, cacao, etc. The principal 
 trade is in Brazil nuts, immense quantities of w^hich were 
 in barges moored in the river. We were shown also the 
 
34 
 
 THE RICE EXPEDITION TO BRAZIL 
 
 sapocaia, a thin-shelled delicious nut which rarely enters 
 into commerce. There was no physician in the town but 
 from conversation with one of the merchants who had 
 
 Fig. 11. Itacoatiari from the river. 
 
 lived in Philadelphia for some time we learned that the 
 place was in point of health similar to the other towns; 
 fairly healthy, some malaria always but more at the end 
 of the rainy season. No mosquitoes were seen. 
 
 Santarem 
 
 Santarem (Fig. 12), six hours distant from Monte 
 Alegre, is situated on the Amazon at the entrance of the 
 Tapajos river. The Tapajos is a black water river and 
 its entrance into the Amazon is marked by the usual 
 sharp line, the admixture of waters taking place slowly. 
 The two streams seem to struggle at the line of junction 
 and masses of the two waters boiling up from below 
 make mutual inroads. The town is divided into two 
 parts, one containing the business houses and more pre- 
 tentious dwellings, and the other chiefly composed of 
 palm houses straggling up a hillside. There is a cathe- 
 dral presided over by a bishop whose house adjoins. 
 On landing we visited one of the physicians of the town, 
 Dr. Nelto, whom we found to be a very courteous and 
 
MEDICAL REPORT 
 
 35 
 
 cultured Spanish gentleman. He lives in a large and 
 comfortable house with wide central hall and big rooms, 
 all paved with tile. In the absence of an interpreter 
 conversation was difficult, but we managed to explain 
 the object of our visit and to ask a few questions. He 
 said there was little sickness just then, the morbidity 
 being greater in the wet season (we were told the oppo- 
 site in Monte Alegre)'. The commonest diseases are 
 malaria and uncinariasis. Leprosy is prevalent and 
 there is a leper colony on a nearby island. There is some 
 
 Fig. 12. Santarem. The cathedral and residence of bishop 
 on the right. 
 
 paratyphoid but no typhoid, as shown by agglutination 
 tests done in Para. We felt very uncertain about this as 
 there is no public laboratory in Para where such tests 
 could be made. With the doctor we went to see two of 
 his patients, both with continued fever, listless, weak, 
 presenting the appearance of typhoid. There seems to 
 be a curious custom of having the patients brought in to 
 see the doctor who remains in the sitting-room with the 
 family and this seemed to entail much hardship on both 
 of the patients. 
 
 We then called upon the bishop, an intelligent Ger- 
 man, who with several Franciscan fathers lived at a 
 house next to the cathedral. He has lived in Brazil 
 
36 THE RICE EXPEDITION TO BRAZIL 
 
 twenty years and previously was stationed in Bahia and 
 Pernambuco. He considered the country as a whole very 
 healthy but thought that leprosy was on the increase. 
 The government pays but little attention to the colony 
 of lepers who fared better in the days of the empire. 
 He confirmed the doctor in saying there was more sick- 
 ness in winter (the rainy season) than in the summer. 
 The people congregate in the town in the winter and go 
 out to the farms in the summer. The bishop makes 
 extensive trips visiting the Indian missions, often travel- 
 ling hundreds of miles in canoes. He told us that the 
 essentials for safety in such travelling were a life pre- 
 server always worn in a canoe, for these vehicles lack in 
 stability, a hammock with mosquito bar, and quinine. 
 The cathedral contains a tablet placed there by the 
 King of Bavaria as a thank offering for the miraculous 
 preservation of the life of the botanist Martins, who was 
 overturned in a canoe near the town. 
 
 The population of the town is from five to seven 
 thousand, always greater in the wet season. We exam- 
 ined the blood of six people, including the fever patients 
 of Dr. Nelto, and all were negative for malarial para- 
 sites. The spleens of these persons were not examined, 
 but on the return trip seven boys were examined and 
 none of these had a palpable spleen. 
 
 The Cities of the Amazon 
 
 Para (Fig. 13), about one hundred thousand inhabi- 
 tants, the capital of the state of Para, which comprises 
 the eastern half of the Amazon valley, lies on the Para 
 river, a great estuary which is connected with the 
 Amazon by numerous channels and formed by the To- 
 cantius and a number of smaller rivers which empty 
 into it. The city is flat, probably at no place more than 
 
MEDICAL REPORT 
 
 37 
 
 forty feet above tide level; the newer part is well laid 
 out in avenues with streets at right angles, but the older 
 part around the water front is more irregular. Formerly 
 yellow fever was endemic and caused yearly a great 
 mortality, but this has now been done away with by the 
 modern methods of control. The streets generally are 
 clean and are planted with mangoes and a very beautiful 
 fig with small, clean, glistening leaves, a very much 
 better tree for tropical cities than the more picturesque 
 
 Fig. 13. Para. The water front. 
 
 banyan, which is also a fig. Formerly the chief tree used 
 for shading the streets was the mango, a beautiful tree 
 giving dense shade but producing much litter, and the 
 irregularities of the trunk allow small accumulations of 
 rain water, in which the yellow fever mosquitoes were 
 said to breed. The mango, however, has the advantage 
 of giving an important food supply by its abundant 
 fruit. The matter of trees in tropical cities is of great 
 importance, for they add greatly to the attractiveness of 
 the city and the comfort of the inhabitants. The fig 
 used here {Ficus Benjamani) with its symmetrical round 
 crown, its fine, clean, glistening foliage, the interesting 
 aerial roots which form attachments with the trunk, 
 
38 THE RICE EXPEDITION TO BRAZIL 
 
 and the fine color of this, makes it the best tree for street 
 planting which we have seen. 
 
 There are many public squares in the city, generally 
 well planted and cared for, containing handsome palms 
 and flowering shrubs. There is a small park of about 
 thirty acres, easily accessible by tram, and containing 
 numbers of fine forest trees, many of which can be seen 
 in their full proportions as much of the lower forest 
 growth has been removed. Two miles from the city is a 
 more extensive park where the original forest has been 
 left intact save for the cutting necessary for the few 
 paths. There is a museum founded by Goeldi in 1894 
 which has a good library and is rich in objects represent- 
 ing the anthropology and natural history of the Amazon 
 region. The garden contains an interesting collection 
 of palms and other trees and a very good collection of 
 the fauna of the region, all well cared for. The whole is 
 under the charge of Dr. Schnetlage, who has herself 
 made a number of explorations and important con- 
 tributions to knowledge. 
 
 The climate is agreeable, though warm, the ther- 
 mometer ranging between 80° and 90°, rarely exceeding 
 these temperatures. The rainfall is large, without great 
 variation between the wet and dry season. The morn- 
 ings are generally warm, but hard showers in the after- 
 noon bring a grateful coolness which lasts through the 
 night. The temperature in the two periods we were 
 there, December and April, though warm was not un- 
 comfortable except during one morning when we made 
 an excursion to the forest (91°). High temperature is 
 recognized as a constant condition and adjustment to 
 this is sought in clothing and housing. Underwear is 
 generally discarded and clothing resolves itself into pan- 
 taloons, shirt, coat, stockings and shoes, and frequently 
 
MEDICAL REPORT 39' 
 
 one or more of these seeming essentials are discarded. 
 The convention in regard to the coat is firmly held, it 
 must be worn on the street, and a coatless man is 
 relegated to the last seats in a tram car, among the 
 laborers. An adjustment of the body to a constant high 
 temperature seems to take place rather quickly, after 
 which the heat does not trouble. The brilliancy of the 
 sunshine, the extreme amount of light, is at first more 
 unpleasant to bear than is the heat, but here also 
 adaptation soon comes. 
 
 Para, under the old name of Belem, which there is 
 some attempt to restore, was formerly much frequented 
 by the tuberculous, an unfortunate choice, for to a 
 climate most unsuitable for this disease were added 
 the dangers of yellow fever and malaria. The people, 
 as seen on the streets and in the shops, the soldiery and 
 the police struck us as being undersized. They do not 
 look happy, there are few smiles and little laughter. 
 This, which was very noticeable on our first visit, did 
 not strike us on our return, for we had become accus- 
 tomed to it. The Portuguese sailors and laborers (im- 
 migrants) are large and muscular men, but possibly less 
 so than the average American laborer. There is no 
 evidence of extreme poverty and beggars are rare. The 
 people were said by Dr. Schnetlage to be extremely 
 kind to one another. A somewhat limited experience 
 in the tropics seems to show, in Anglo-Saxon women, a 
 tendency to thinness in contrast to those of their sisters 
 who have felt even remotely the touch of the tar brush. 
 The population embraces many nationalities and there 
 are all sorts of admixtures with the negro. 
 
 Para was the first city founded in Brazil and it has 
 played an important part in the history of the country, 
 particularly in the first half of the last century, when 
 
40 
 
 THE RICE EXPEDITION TO BRAZIL 
 
 the monarchy was founded and the country became 
 independent. It will further always be known from the 
 writings of the remarkable group of explorers who stud- 
 ied the Amazon region about the middle of the last cen- 
 tury. Martins, Bates, Spruce, Wallace, Agassiz, all spent 
 some time here. When Bates was here in 1847 the city 
 stood on the edge of the primeval tropical forest, which 
 is now represented only in the large park at the water- 
 
 FiG. 14. The public hospital of Para. 
 
 works. He lived at St. Nazareth in a small house at the 
 edge of the forest which has now disappeared. His 
 descriptions of the forest as he then saw it apply 
 perfectly to the conditions seen in the large park. 
 
 Para has an excellent public hospital (Fig. 14), not 
 only the best in the Amazon cities, but one which will 
 bear comparison with municipal hospitals anywhere. 
 It is a large, well constructed stone building, in the 
 eastern section of the city, and with its garden and 
 courts covers an entire city block. There are twelve 
 wards, each containing thirty-five beds, giving accom- 
 modations for at least three hundred and fifty patients. 
 
MEDICAL REPORT 
 
 41 
 
 The wards are large and airy and open into a long cor- 
 ridor by folding doors. It was remarkable to see no 
 screens and yet an entire absence of flies and, certainly 
 during the day, of mosquitoes. In the courts between 
 the wards (Fig. 15) there are well cared for gardens 
 with handsome palms and quantities of flowers; every 
 window looks upon a pleasing scene. It is under the 
 care of a sisterhood, is scrupulously clean, and the 
 
 Fig. 15. Pubi.ic hospital. Coxjrt between wards. 
 
 patients are well cared for. There are good operating 
 rooms. X-ray rooms, and the general equipment in 
 instruments and appliances is good. There is, however, 
 no pathologist and no system of resident internes, and 
 post mortem examinations, so important for stimulating 
 the scientific spirit and general morale of a hospital, are 
 not made. The hospital is supported by the free will 
 offerings of the people through a hospital association 
 with initiation fees and yearly dues, to which every per- 
 son who can afford it belongs. We were told that 
 membership in the association confers a certain social 
 
42 
 
 THE RICE EXPEDITION TO BRAZIL 
 
 prestige. Dr. Utra Vas, who is the chief surgeon of the 
 hospital, was very kind and showed us the cases in 
 the wards. The doctor was educated in England and in 
 Germany and speaks both languages with facility. He 
 has large offices, well fitted with modern appliances and 
 a number of assistants who take care of the laboratory 
 examinations and do much of the special work, the whole 
 forming a well organized surgical clinic (Fig. 16). In 
 
 Fig. 16. Interior of ward. The beautiful floor is formed of 
 
 ALTERNATING BOARDS OF ITAUBA (bLACK) AND AMARILLA (yELLOW) 
 WOODS WHICH ARE ALMOST INDESTRUCTIBLE. 
 
 the wards we saw a number of types of the Leishmania 
 ulcers which were treated with hypodermic injections 
 of antimony, and a number of cases from the rivers 
 with the immense spleens with which we had become 
 familiar. 
 
 We append what health statistics we have been able 
 to acquire, together with other data. The records of 
 later years are not accessible. The estimate of popu- 
 lation is certainly erroneous, for the cities here see their 
 population under a magnifying glass, a fault to which 
 those of other countries are not immune. The statistics 
 
MEDICAL REPORT 43 
 
 are probably not very reliable as is shown in the varia- 
 tions in the number of deaths from certain common 
 diseases. The very low incidence of tumors is in accord 
 with our observations everywhere we went. The very 
 striking decline in mortality from yellow fever is the 
 result of preventive measures instituted in 1911. The 
 average yearly temperature and rainfall is given for but 
 tw^o years. 
 
 Population Average Rainfall 
 
 Year (estimated) temperature in inches 
 
 1907 185,000 
 
 1908 185,000 
 
 1909 185,000 
 
 1910 190,000 80.9° F. 107.21 
 
 1911 1 190,000 80.4° F. 100.4 
 
 1912 2 200,000 
 
 1 All data for the years 1912, 1913, and 1914 were obtained from the Office International d'Ey- 
 giene Publigue annual reports for those years. All other data, with the exception of the population 
 estimates for the years 1907, 1908, and 1909 obtained from the consular reports, were taken from the 
 Annuario de Estatisttca Demographo-Sanitaria for the years 1910 and 1911. These two reports were 
 published in 1913 and 1914 respectively. 
 
 2 The 1911 report of mortality statistics combined certain causes as indicated in the chart on 
 pp. 44 and 45. 
 
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46 THE RICE EXPEDITION TO BRAZIL 
 
 Manaos 
 
 Manaos, known formerly as Barra, has a fine situa- 
 tion on high ground on the north bank of the Rio Negro, 
 nine miles above the entrance of this into the Amazon. 
 The Rio Negro is a clear black water river and there is a 
 sharp line marking the junction of its waters with the 
 turbid yellow stream of the Amazon, which can be fol- 
 lowed for many miles. The city is the centre of the 
 rubber industry of Brazil and during the period of high 
 prices for rubber which was terminated by the present 
 war, was very prosperous. Most of the steamers which 
 serve the river trafiic of the central and most of the 
 western part of the Amazon valley make this their home 
 port. The city is not lacking in picturesqueness ; there 
 are handsome wide avenues well planted with fig and 
 mango trees, the public squares are numerous, beautiful 
 and well cared for, but there is no public park. The 
 theatre, situated on the highest land in the city with a 
 dominating dome of blue glazed tile forms the most con- 
 spicuous object and focuses the civic pride. The build- 
 ing is poorly constructed and in bad taste. There are 
 some very good public buildings and the foundations of 
 others, the funds appropriated for their construction 
 having disappeared before the buildings could get 
 higher. There is a dignified old cathedral in the middle 
 of a fine square, but the whole city is very different from 
 the quiet and dignity of Para and gives one the impres- 
 sion of a rapidly developed frontier town seen in its most 
 unfortunate time, that is, at the decline of a period of 
 great expansion. The rise of the city really dates from 
 1807 when the capital of the province was transferred 
 from Barcellos here. In 1829 when Mar was here he esti- 
 mated the population at three thousand. It increased 
 
MEDICAL REPORT 47 
 
 rapidly with the rise of the rubber industry which reached 
 its acme in 1913-14. Great wealth flowed into the city, 
 and with this came adventurers from the entire world 
 to share in the prosperity. Even now there is probably 
 no city of its size with such a cosmopolitan population. 
 The hospital is an old structure totally inadequate 
 and dirty. Mar speaks of the hospital as a spacious 
 
 Fig. 17. Court in the Manaos hospital. 
 
 structure which had just been completed, and no doubt 
 it then and for a considerable period fully sufficed for 
 the needs of the city. It is rather curious that at a 
 time when there was much yellow fever in the place 
 some of the money expended in the costly and showy 
 theatre should not have been turned to giving better 
 conditions for the sick (Fig. 17). The only circum- 
 stance favorable to the hospital lies in the statement of 
 the physicians that it was formerly much worse than 
 at present. In addition to this public hospital there 
 is a smaller hospital, called the Portuguese, which is 
 
48 
 
 THE RICE EXPEDITION TO BRAZIL 
 
 entirely for pay patients, is well provided and seemingly 
 well managed. It is conspicuous from the harbor, 
 standing on an eminence and still shows the ruin pro- 
 duced four years ago when it was subjected to a bom- 
 bardment from a government man-of-war in the harbor. 
 This was on the occasion of a gubernatorial election 
 when the local authorities were not in full sympathy 
 with the government. A small military hospital 
 
 !► 
 
 
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 1 
 
 Fig. 18. Manaos military hospital. 
 
 (Fig. 18) stands just outside of the city. On either side 
 of the city there are igarapes which extend a consider- 
 able distance inland, and in the expansion which the 
 city underwent during the period of prosperity streets 
 were run across these ravines without adequate provi- 
 sion for drainage, leading to the formation of large pools 
 which served for mosquito breeding. The banks were 
 endemic foci for yellow fever. 
 
 The city offers an interesting example of what may be 
 accomplished by one man with the great possessions of 
 knowledge, intelligence, public spirit, and energy. This 
 rare combination has enabled Dr. H. Wolferston Thomas 
 
MEDICAL REPORT 49 
 
 to accomplish the wonderful work he has done here. 
 Thoroughly trained in the Liverpool School of Tropi- 
 cal Medicine, and with an accomplishment of valuable 
 researches in this field, his work has been accurate, 
 scientific, controlled by laboratory and experimental 
 methods, and he is untiring. He is physician, coun- 
 selor, and friend to the English colony, extends his 
 influence in all directions in which he can be of service 
 and he has won the respect and admiration of the local 
 physicians and the people. Such an accomplishment 
 by a man working alone without the sympathy and 
 encouragement which come from association with men 
 engaged in similar work is remarkable. He lives in a 
 house which combines in it a small hospital. During the 
 prevalence of yellow fever he was very successful in its 
 treatment, the essential principle of which was the 
 ingestion of vast quantities of carbonated water. The 
 measures for the eradication of the disease undertaken 
 in 1913 were under his direction. 
 
 There seems to be a good deal of leprosy. Early 
 anesthetic forms of this were seen in the general hospital 
 and there is a small leper colony a few miles from the 
 city where twenty-four cases are segregated. As this 
 seemed a small number the question was asked whether 
 these were all the cases in the district, and the reply was 
 " Why no, there are possibly one thousand." The cases 
 seen were advanced tubercular and mutilating forms 
 and probably only the most advanced and evident cases 
 are sent here to be cared for. The colony is well placed 
 on high land on the bank of the river, there are abundant 
 fruit trees and vegetable gardens, the small necessary 
 care of which is given by the lepers, the river furnishes 
 fish and the cost of the asylum is small. The buildings, 
 though adequate, are mere shacks. One man, who 
 
50 
 
 THE RICE EXPEDITION TO BRAZIL 
 
 seemed to be of a somewhat higher social status than 
 the others, lived alone, had his own garden, fruit trees, 
 and poultry, which he tended, and the palm house 
 (Fig. 19) which he had built himself was well constructed 
 and clean. He has directed that when he is dead the 
 house shall be burned with his body. 
 
 The city has an excellent and adequate water supply. 
 The abattoir system and the distribution of meat is 
 
 Fig. 19. Leper and house which he has built. 
 
 interesting and the same in the three Amazonian cities 
 Para, Manaos, and Iquitos. Cattle are very abun- 
 dant and cheap. They are brought to market directly 
 from the pastures, and when alive seem to be in good 
 condition, but when slaughtered the meat as seen in the 
 markets has not an appetizing appearance. The blood 
 seems to undergo rapid hemolysis and all the flesh has 
 the diffuse hemoglobin stain. The cattle are killed in 
 the abattoirs after four o'clock in the afternoon and the 
 meat distributed to the markets and provision stores 
 
MEDICAL REPORT 51 
 
 during the night, being carried either by bullock carts 
 or as in Para by the tram cars. No fresh meat can be 
 sold after 11 a.m., and there is a rapid fall in price as 
 this hour is approached. It might seem that an improve- 
 ment could be effected by keeping the meat in cold 
 storage for a couple of days before consumption as all 
 of these cities have local ice plants. 
 
 Milk, both in the cities and in the country, plays but 
 a small part in the food of the people. It is all boiled 
 before using and is not a pleasant drink. In the Autaz 
 region, where the raising of cattle is the main industry, 
 there was considerable consumption of milk in the form 
 of menhada, or clotted milk, which was delicious. Both 
 in Manaos and in Iquitos we saw goats driven along the 
 streets and milked at the house doors, the product being 
 used for children. In Itacoatiari we saw early in the 
 morning the conventional milk cart dispensing milk 
 from a large tin receptacle. 
 
52 
 
 THE RICE EXPEDITION TO BRAZIL 
 
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MEDICAL REPORT 
 
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54 THE RICE EXPEDITION TO BRAZIL 
 
 Death Rate 
 
 Population Death rate 
 
 Year (estimated) Deaths per 1000 
 
 1907 50,000 1438 28.7 
 
 1908 50,000 1764 38.5 
 
 1909 50,000 1638 32.7 
 
 1910 60,000 2196 36.6 
 
 1911 60,000 2333 39.0 
 
 1912 60,000 1921 32.0 
 
 1913 70,000 (.?) 1687 24.1 (?) 
 
 1914 70,000 (?) 1305 18.6 (?) 
 
 1915 70,000 (?) 1197 17.1 (?) 
 
 1916 70,000 (?) 1165 16.6 (?) 
 
 Here it seems possible that the very low incidence of 
 cancer may be partly explained by cases wrongly in- 
 cluded under " Diseases of the Digestive System " and 
 possiblj^ cirrhosis of the liver also falls under this cate- 
 gory. The apparent fall in death rate since 1913 is 
 readily explained. It was influenced somewhat by the 
 fall in deaths from yellow fever, but the great factor has 
 been the decline in population. That this has dimin- 
 ished in the last four years thirty to forty per cent is a 
 matter of common knowledge, the fall being coincident 
 with the decline in importance of the rubber industry. 
 Cutting down the given estimate of population one half 
 would give what is probably nearly the correct figure of 
 33.3 instead of 16.6. 
 
 The rainfall as given is somewhat less than that of 
 Para, and the temperature is about the same as Para. 
 
 Iquitos 
 
 Iquitos is the third in size of the Amazon cities and is 
 situated on the Amazon in Peru two hundred miles 
 from the Brazilian border and twenty -three hundred 
 miles from the mouth of the river. It has only recently 
 attained any importance. Mar, who crossed the Andes 
 from Truxillo in 1829, and came down the river, speaks 
 
MEDICAL REPORT 55 
 
 of it as a pueblo not surpassing in size and number of 
 inhabitants those he had passed through in the moun- 
 tains. Herndon, who passed through it in 1853, speaks of 
 it as composed of about two hundred and fifty fishermen 
 and inferior in importance to most of the Brazihan towns 
 on the river. The city hes on a high bank about eighty 
 feet above the level of the river at the time we were 
 there, December 29 to January 3. It is a centre for the 
 collection and export of rubber and since the decline in 
 price of that commodity the population has decreased 
 from 18,000 to 12,000. The river shore forms the most 
 interesting and picturesque part of the city. Boats of 
 all sorts lie moored to the bank and quite a population 
 dwells upon them and may be seen in the daily w^ork of 
 bathing, washing clothes, and cooking. Among these 
 boats are large rafts which have come down from the 
 smaller rivers, making journeys often of several hundred 
 miles. On the raft is a thatched house and accommoda- 
 tions for cattle and poultry, which are carried for food on 
 the way or disposed of in the city. Both cargo and raft 
 are sold, the latter for firewood, and the return journey 
 is made in a steamer or in a canoe which is towed down. 
 The bank is grown up with patches of magnificent calla- 
 diums, the leaves often four feet long and two broad, 
 cannas and many flowering plants. The houses in 
 places straggle down the bank, assuming picturesque 
 but apparently unstable attitudes. The streets are 
 either very badly paved or not at all, and the drainage 
 is conducted in side ditches with pools at intervals. 
 There is no general water supply, water being provided 
 by wells, cisterns, and natural springs in or near the 
 city, or pumped up from the river. There is but one 
 very badly kept public square, with a few almond trees 
 which with their pyramidal shape and tiers of horizontal 
 
56 
 
 THE RICE EXPEDITION TO BRAZIL 
 
 branches are always pleasing, but here more or less 
 broken and unkempt. There are no tramways or pleas- 
 ure vehicles; joy riding being served only by a narrow 
 gauge railroad which though ordinarily used for freight 
 only, on holidays runs, at long intervals, a train of tiny 
 passenger cars a short distance into the country. The 
 people as a whole look fairly well and have more pleas- 
 ing faces than have the Brazilians. Many more Indians 
 are seen, fewer negroes than lower down, and the admix- 
 ture is rather with the Indian than with the negro. 
 
 Fig. 20. Military hospital at Iquitos. 
 
 There is a hospital of forty beds situated about two 
 miles from the centre of the city which though under the 
 care of the army also serves as a municipal hospital 
 (Fig. 20). There is a male and female ward and between 
 them a small pavilion for administration. All parts 
 of the hospital were clean and the patients seemed well 
 cared for. The wards contained numerous cases of 
 ulcers which were diagnosed as Leishmania. One of 
 these was owned by an Irishman, fifty-seven years old, 
 who had come from the Cordilleras, and had been four- 
 teen months in the hospital. The physician in charge, 
 Dr. Mantero, was very kind in showing us the wards 
 and giving information. We used as interpreter one of 
 the ubiquitous Barbados negroes. Dr. Mantero said 
 
MEDICAL REPORT 
 
 57 
 
 malaria was not common in Iquitos but there was much 
 in the surrounding country. Occasional cases of dysen- 
 tery, both the amoebic and bacillary type, came to the 
 hospital and this disease was more common on the Napo 
 river. Tuberculosis was fairly common, and hookworm 
 the great scourge affecting eighty per cent of the popu- 
 lation; twenty per cent of the cases were of the grave 
 form of anaemia produced by this. Tropical ulcers were 
 common and did well under 
 local antiseptic treatment ; the 
 intravenous injections of anti- 
 mony of which we had heard 
 so much in Para and Manaos 
 were not used. It was also 
 very evident that under the 
 name of tropical ulcer all sorts 
 of conditions, both the ordi- 
 nary varicose ulcer and skin 
 carcinoma, were included. On 
 the way from the hospital we 
 crossed a ravine where there 
 are several springs, the water 
 of which is used for washing, 
 and forms a large part of the regular water supply of 
 the city, into which it is carried in large jars. The 
 washing was being done in pools below the springs. 
 There were many children playing in the vicinity and 
 a number of houses were above the springs which were 
 low, the surface water draining into them. All of the 
 children seen here were anaemic and evidently infected 
 with hookworm. Dr. Mantero thought that the prin- 
 cipal mode of extension of the hookworm infection was 
 by drinking water contaminated with the embryos of 
 the hookworm. 
 
 Fig. 21. 
 
 Tubercular leprosy. 
 Iquitos. 
 
58 THE RICE EXPEDITION TO BRAZIL 
 
 In the leper hospital, which is on the outskirts of the 
 city, there were eight cases, of well marked and advanced 
 tubercular leprosy (Fig. 21). 
 
 The appended health report of the city for 1916 is 
 interesting but we should not care to say that it is 
 reliable : 
 
 Health Report of the City of Iquitos, Peru 
 
 1916 
 
 Deaths in 1916 285 
 
 Births in 1916 976 
 
 Causes of Death 
 
 *Not specified , 130 
 
 Tuberculosis 30 
 
 Pulmonary 11 
 
 Generalized 10 
 
 Abdominal 1 
 
 Larynx 2 
 
 Pott's disease 2 
 
 Other organs 4 
 
 Anaemia 7 
 
 1 f\ 
 
 Intestinal parasites 9 / 
 
 (Both probably refer to ankylostomiasis) 
 
 Acute intestinal diseases 20 
 
 Diarrhea: children less than 2 years 9 
 
 Diarrhea : children more than 2 years 5 
 
 Dysentery 6 
 
 Malaria 11 
 
 Measles (" serampion ") 10 
 
 Acute respiratory infections 14 
 
 Broncho-pneumonia 10 
 
 Lobar pneumonia 1 
 
 Bronchitis 1 
 
 Grippe 1 
 
 Gangrene of Iimg 1 
 
 Syphilis.. . 2 
 
 Aneurysm 3 
 
 General paresis 1 
 
 Cancer 3 
 
 Female genital organs 2 
 
 Other organs 1 
 
 Tetanus 4 
 
 Cirrhosis 3 
 
MEDICAL REPORT 59 
 
 Accidents of pregnancy 1 
 
 Puerperal septicaemia 2 
 
 Congenital debility 4 
 
 Still born 2 
 
 Suicides 5 
 
 Poison 1 
 
 Fire-arms 4 
 
 Accidental drowning 4 
 
 Accidental burning 1 
 
 Yellow fever 1 
 
 Rheumatism 1 
 
 Asthma 1 
 
 Chorea 1 
 
 In looking over this report, which on its face is obvi- 
 ously imperfect, the first item showing the great excess 
 of births over deaths is striking, when it is considered 
 that the city has a declining population. The probable 
 explanation is that deaths, particularly those of children, 
 are not reported, and some confirmation is given to this 
 by the small number of deaths due to infantile diseases. 
 Another striking feature in the report is that not a 
 single death is reported as due to cardiac and renal dis- 
 ease. In the non-specified deaths Dr. Ferradas, the port 
 physician, and a man of intelligence, thought that fifty 
 per cent of these were due to ankylostomiasis, which if 
 true would make this the most common cause of death, 
 and it is not improbable that some cardiac and renal 
 cases were included under this category. Still we saw 
 no such cases in the hospital and the physicians said 
 they were very rare. We thought that there might be 
 some relation between this and longevity and en- 
 deavored to ascertain something regarding the age at 
 death by visiting the cemetery and getting the recorded 
 ages from the stones, but the cemetery though well 
 kept and interesting in the varieties of trees which had 
 been planted, did not give such information. In most 
 cases age was not given and the average of the sixty 
 
60 THE RICE EXPEDITION TO BRAZIL 
 
 ages which we found was 25.73 which if of any value did 
 not bear out our hypothesis that Hfe in Iquitos was of 
 short duration. Of the sixty cases eight were more than 
 sixty years and there was one of eighty and one of 
 ninety-two. Another interesting feature in the report 
 is that but three deaths from cancer are recorded. While 
 the recorded death causes are usually those of obvious 
 diseases, still cancer of the breast and epidermoid can- 
 cers, superficial tumors, etc., are sufficiently obvious. 
 Here as elsewhere in the Amazon valley tumors of all 
 sorts, both benign and malignant, appear to be relatively 
 rare. We were told that malaria was rare and in the 
 report but eleven deaths are set down as caused by it, 
 and while in the city we saw very few mosquitoes. Why 
 malaria is not common here is one of the many puzzling 
 features of this disease we encountered. More favorable 
 conditions for mosquito propagation could not be con- 
 trived, and infected individuals are constantly coming 
 here from the rivers, both above and below. In death 
 reports the tendency would be to attribute more rather 
 than less cases to this cause. 
 
 Such a health report as this with all-its obvious imper- 
 fections is better than none at all, for it represents a 
 desire to do something, to make some contribution to 
 knowledge and from such beginnings more perfect work 
 will proceed. 
 
 Conditions on the Rio Negro 
 
 The Rio Negro, one of the main tributaries of the 
 Amazon, carries into this the drainage of an enormous 
 area provided with a great rainfall. This area com- 
 prises the northern Amazonas bordering on British 
 Guiana, Venezuela, and Colombia, as well as nearly the 
 entire western watershed of Colombia. It receives a 
 
MEDICAL REPORT 
 
 61 
 
 number of rivers, the largest of which are the Rio 
 Branco, the Uaupes, and the Guainia. The lower four 
 hundred miles of the river has much the character of a 
 lake, the fall is very slight, the river is broad and there 
 are great numbers of islands. Most of these islands are 
 formed of (Fig. 22) igapo, that is, land ordinarily a few 
 feet only above the surface and completely submerged 
 during high water. The true banks of the river are 
 
 Fig. 22. The lower Rio Negro. Clusters of javary palms. 
 
 formed of terra firme, but igapo and varzea extend to a 
 considerable distance along the smaller entering rivers. 
 There is a great rise of the river during the wet season, 
 more pronounced in the lower than in the upper part. 
 San Isabel, five hundred miles from Manaos, is at the 
 head of steam navigation and the river commencing 
 some eighty miles below this changes its character, is no 
 longer so wide, the islands are less numerous, the cur- 
 rent more rapid, and the banks composed of granite. 
 Many of the islands have a granite foundation and single 
 projecting granite rocks are seen (Fig. 23). Above 
 
62 
 
 THE RICE EXPEDITION TO BRAZIL 
 
 San Isabel all these conditions are more pronounced and 
 the river has the character of one coming from a high 
 granite country. There are numerous and extensive 
 sand bars due to the disintegration of the granite above 
 which seems to be proceeding rapidly. The name of the 
 river is appropriate to the color of the water which 
 though perfectly clear, is a pale amber as seen in a 
 glass, and the mass of water is jet black. At the time we 
 were on the river, January to April, there was little 
 
 Fig. 23. The Rio Negro. Granite formation. 
 
 wind, an occasional squall or rainstorm, but usually the 
 river had a glassy surface giving a perfect mirror. The 
 ever present clouds of the day and the starlit sky at 
 night reflected from the black surface were of wonderful 
 beauty. The rainy season, with its period of high water, 
 is from March to June, but there is usually a temporary 
 rise in December. The rise is very great, the entire 
 lower part of the river and the islands being flooded. 
 The entire country on both sides of the river is heavily 
 forested, there being merely small clearings for pastures 
 about the villages and the sitios where the large rubber 
 merchants live. 
 
 The population along the river is extremely scarce. 
 Senhor Netto, an intelligent gentleman, the governor of 
 
MEDICAL REPORT 63 
 
 the district of Barcellos, estimates the population from 
 Manaos to the Venezuelan border, a distance of seven 
 hundred miles, at not more than five thousand. There 
 is no census and this estimate is based on the amount of 
 rubber which the country produces. The population is 
 along the rivers, the great stretches of forest between 
 being uninhabited, save by the few wandering, forest 
 Indians. The country has also never been explored, 
 the heights, the character, and the relations of the 
 several mountain ranges have never been determined. 
 
 There seems little doubt that the region was formerly 
 more thickly settled than at present, as shown by the 
 ruined churches in the villages and by the traditions of 
 population. Before the days of rubber production it 
 was an agricultural region, quantities of coffee, corn, 
 cacao, rice, vanilla, anatto, and indigo being produced. 
 Senhor Netto attributes the decline in population to 
 several factors, such as the introduction of disease by 
 the traders, the development of the rubber industry 
 which caused the people to neglect agriculture, and with 
 all this the extension of alcoholism. The climate is 
 good, the nights cool, the insect pests, save in certain 
 places, are not very bad, and the soil is fertile. 
 
 The Lower River 
 
 From the view point of disease there is a sharp separa- 
 tion between the lower and upper river at San Isabel, the 
 head of steam navigation. From Manaos to San Isabel 
 and on the return we made numerous stops, sometimes 
 for a few hours only, at others for several days, and 
 there was opportunity for study of the people. There 
 are many Indians and a large admixture of Indian 
 blood, comparatively few negroes and mulattoes. The 
 pure whites are of various nationalities, but chiefly 
 
64 THE RICE EXPEDITION TO BRAZIL 
 
 Portuguese. The people seen presented the indications 
 of ill health; the nutrition was poor, there was evident 
 anaemia and lack of energy. 
 
 Malaria in the Cities 
 
 In Para, Manaos, and Iquitos there are doctors, 
 hospitals, and more or less efficient health departments. 
 Hospital and city officials extended us every courtesy 
 making it possible to collect considerable data regarding 
 malaria and other endemic tropical diseases during our 
 brief visits. Annual health reports are published in all 
 three cities, and in Manaos there are monthly reports 
 extending back for a period of ten years. 
 
 According to these reports malaria is not only the 
 commonest disease of the country, but is the direct 
 cause of much the largest number of deaths. The figures 
 are quite astounding. For example, in Manaos, out of 
 a total of 15,500 deaths in the last ten years, 4250, or 
 28 per cent are attributed to malaria. Pulmonary 
 tuberculosis, the next most common cause, was respon- 
 sible for 1136 deaths, or 7 per cent of the total. It may 
 be explained that the tuberculosis rate is almost as high 
 as in New York, where this disease stands first or second 
 among the causes of death. According to these statis- 
 tics then, malaria causes four times as many deaths as 
 any other single disease, a number relatively five times 
 as great as that of any one disease in New York. The 
 death rate in Manaos from all causes, cannot be accu- 
 rately stated since the population has varied so much in 
 the last ten years. It is probably high, that is, 35 per 
 1000 or more. That of Para is somewhat lower. 
 
 Are these figures regarding the mortality from malaria 
 reasonably accurate "^ Our investigations, though brief 
 and incomplete, would indicate that they are not and 
 
MEDICAL REPORT 65 
 
 we are inclined to think that malaria does not cause half 
 as many deaths as are attributed to it. In the first 
 place, diagnosis is practically never confirmed by 
 microscopic examination of the blood. In the eight 
 hospitals visited, we saw only a single microscope. This 
 was in a small sanitarium in Manaos, owned by an Eng- 
 lish doctor whose practice is limited to the English 
 colony. Secondly, we got the impression that, as a 
 general rule, correct diagnoses were made only on cases 
 where the nature of the disease was obvious, such as 
 leprosy or dysentery, and where there was doubt, ma- 
 laria was the diagnosis most often set down. It is the 
 scrap pile, as it were. Thirdly, during our three stops 
 at Manaos, where we were altogether nearly three 
 weeks, we made a number of visits to the 300-bed muni- 
 cipal hospital, but we never saw a single case of severe 
 or fatal malaria. One case diagnosed as such was autop- 
 sied by us and found to be pneumococcus meningitis. 
 
 We did see, however, any number of people in the 
 hospital with enlarged, hard spleens, who gave a history 
 of fever. Most of these cases had been admitted for 
 other troubles, such as dysentery and tropical ulcer. 
 In one ward, containing twenty ulcer cases, there were 
 ten with easily palpable spleens. There can be little 
 doubt that malaria is very prevalent in the cities and 
 towns, as well as in the country, but our observations 
 would indicate that the number of deaths directly attrib- 
 utable to it is much lower than the statistics show. 
 
 In Monte Alegre, Santarem, and Obidos, towns on the 
 lower Amazon, conditions as regards malaria are about 
 the same as in Para and Manaos. At least one doctor 
 or pharmacist was found in each place. The doctors and 
 others with whom we talked told us that chills and 
 fever were common toward the end of the rainy season 
 
66 THE RICE EXPEDITION TO BRAZIL 
 
 especially, but that the infection responded readily to 
 quinine, which was often administered subcutaneously. 
 The people looked healthy and our blood specimens were 
 negative except in three cases. We saw no big abdo- 
 mens or enlarged spleens such as were a common sight 
 on the Rio Negro. We saw at Santarem three cases of 
 fever, which the attending doctor diagnosed as malaria. 
 The patients were being treated with quinine without 
 effect, and the cases looked to us like typical typhoid 
 fever. The doctor, however, insisted that typhoid fever 
 did not exist in that section. 
 
 Malaria on the Rio Negro 
 
 Our stay of several months on the Rio Negro afforded 
 a better opportiuiity for the study of medical conditions 
 than was possible in the cities, where our visits lasted 
 only a week or two at the most. There are no doctors on 
 the river. In fact the entire stretch of country between 
 Manaos and Bogota, a distance of more than a thousand 
 miles, is without medical aid of any kind. Medicines, 
 except the herb and plant extracts of the Indians, are 
 obtained only through the slow and infrequent com- 
 munication with Manaos. 
 
 At every settlement sick people were examined and 
 questioned, blood smears taken and facts regarding the 
 diseases of the section obtained from the more intelli- 
 gent members of the community. The number exam- 
 ined at different places and the results of blood and 
 spleen examinations are indicated in Table I. On the 
 lower river, that is, that part between Manaos and San 
 Isabel, conditions were everywhere very much the same, 
 and very deplorable. In some settlements, such as, for 
 example, Carvoeiro and Moura, near the mouth of 
 the Rio Branco, scarcely a single healthy person could 
 
MEDICAL REPORT 67 
 
 be found. Practically all of the children and many of 
 the adults had prominent abdomens and big, hard, 
 easily palpable spleens which in some instances almost 
 filled the abdomen, and all were more or less anaemic and 
 weak. No one was able to do a real good day's work. 
 A history of fever could be obtained from many, but 
 there were quite a number of children with big spleens, 
 who according to their parents had never suffered from 
 chills or fever. Our limited knowledge of the language 
 spoken made it difficult to get accurate information. 
 (Portuguese is the language of the country, but many of 
 the Indians know only their native tongue, — Tupi- 
 guarani or Lingo-geral, as it is called.) Cases showing 
 acute symptoms were rarely encountered and in the 
 blood of these few, parasites were easily demonstrated. 
 Blood smears of the majority of the children, however, 
 with big, hard spleens and moderate anaemia were 
 negative, although a prolonged search through several 
 smears sometimes was rewarded by the discovery of 
 a single organism, usually of the aestivo-autumnal 
 variety. 
 
 That the weakness and anaemia and large spleens 
 were in all cases the result of chronic malarial infection 
 is doubtful. Examination of the faeces of several very 
 anaemic children showed numerous hookworm ova. 
 The presence of an eosinophilia in at least 80 per cent of 
 the people is also an indication of wide-spread hookworm 
 infection. In many instances, the eosinophiles were 
 more than 20 per cent. (See table.) The table shows 
 also a high mononuclear count, which may be referable 
 to the chronic malaria. 
 
 On the upper portion of the river, that is, between 
 San Isabel and San Gabriel, the people looked much 
 healthier. Practically no big spleens were found and a 
 
68 THE RICE EXPEDITION TO BRAZIL 
 
 history of malaria was rarely obtained. Blood smears 
 were negative in all cases. 
 
 It may be of interest to compare the manifestations 
 of malaria such as we found in the Amazon region with 
 those observed in other malarious countries. Koch in 
 West Africa and New Guinea, James, Stevens, and 
 Christophers in India, Pause in East Africa, Plehn in 
 the Kamerun, Craig in the Philippines, and Daniels in 
 Guiana have given good descriptions of malaria in the 
 respective countries. It is evident from a review of 
 their observations, that endemic malaria may manifest 
 itself differently in different countries and peoples. At 
 least three general types of infection may be recognized : 
 
 1. An infection characterized by the presence of 
 numerous parasites in the blood, especially in children 
 under ten years, with little or no disturbance in health. 
 The infection disappears without treatment as the child 
 grows older. There is no febrile reaction and no evident 
 anaemia or weakness. Koch describes the condition in 
 West Africa and New Guinea, where he found organisms 
 in the blood of every child under two years; in 48 per 
 cent of those between two and five years and 23 per 
 cent of those between five and ten years; none in those 
 over ten years. Craig gives similar figures for native 
 Philippine children; he also found a large percentage 
 of " healthy " adults, harboring parasites in large num- 
 bers. The condition is also described by James in India, 
 Pause in East Africa, and Plehn in the Kamerun. 
 Plehn, who saw many of these " carriers " among adults, 
 says they sometimes, but rarely, develop chills and 
 fever. When they do it is exceptional to see more than 
 one chill, even when no quinine is administered. All of 
 the authors refer to the state as one of partial immunity, 
 probably inherited. It may be thought of as a sort of 
 
MEDICAL REPORT 69 
 
 mutual adaptation of host and parasite, or symbiosis, 
 such as is seen in the rat trypanosome infections, where 
 the animal remains healthy even though his blood be 
 teeming with parasites. Not a single example of this 
 type of infection was found by us in Brazil. 
 
 2. A chronic infection characterized by moderate 
 anaemia, weakness, and splenic enlargement which is 
 sometimes extreme, and by an absence or great scarcity 
 of organisms in the circulating blood. This condition 
 corresponds probably to the so-called " malarial cach- 
 exia " of many writers. In certain parts of India, this 
 type of infection is very common. Koch does not men- 
 tion it in South Africa or New Guinea, and it was not 
 seen by Craig in the Philippine natives. In the Amazon 
 region it is the type of infection which predominates; 
 in fact, at least 90 per cent of the cases we saw could be 
 placed in this group. The splenic enlargement is not a 
 constant feature according to Daniels, who says that in 
 Guiana, where malaria is extremely prevalent, malarial 
 spleens of great size are rare. His observations are 
 based largely on autopsy findings. He thinks there may 
 be some other factor than malaria, which is responsible 
 for the huge spleens sometimes seen in malarious dis- 
 tricts. On the Rio Negro, as we have pointed out, 
 extreme splenic enlargement was the most striking 
 feature of the cases. 
 
 3. The ordinary type of infection as we see it in 
 susceptible temperate-zone people who visit the tropics 
 is periodic attacks of chills and fever, with progressive 
 anaemia, etc. With this manifestation of malaria, 
 everyone is, of course, familiar. In the Philippines an 
 outbreak of chills and fever in a camp of American 
 soldiers led Craig to look for the source of infection 
 among the natives living close by. Although none 
 
70 THE RICE EXPEDITION TO BRAZIL 
 
 were having chills or fever or looked chronically ill, 
 Craig found any number of " carriers " among them, 
 showing that the striking difference in reaction in the 
 Americans and natives was due to a difference in host 
 and not in the type of malarial organism concerned. In 
 our expedition, the single member of the party who con- 
 tracted malaria, developed typical chills and fever on 
 alternate days; while on the lower Rio Negro, where he 
 got the infection (Fig. 24), chills and fever are rarely 
 seen, nearly all of the cases exhibiting the chronic 
 cachetic state. 
 
 Summary 
 
 1. Malaria in chronic form is extremely prevalent in 
 the Amazon Valley, both in the cities and in the sparsely 
 settled districts along the rivers. It is the cause of much 
 poverty and misery, and is one of the chief causes of the 
 country's lack of development. 
 
 2. Examples of severe acute or malignant malaria 
 were not observed, but we were told that on certain 
 rivers, especially the Madeira, not visited by us, fatal 
 attacks were common. Statistics indicating high 
 mortality of malaria in cities are of doubtful accuracy. 
 
 3. A relatively small number of cases examined 
 showed organisms in the circulating blood, eleven out of 
 one hundred and fifty -three or 7.2 per cent. Had we 
 taken blood smears from the entire population, instead 
 of selecting, in many places, those who looked ill or were 
 complaining, the percentage of positives would have 
 been still smaller. On the other hand, a more exhaus- 
 tive search through several smears from each individual 
 would probably have increased the number of positives. 
 Indeed, a second examination of twenty slides from 
 cases in which there was a definite history of malaria 
 
% 
 
 ^ 6 
 
 li 
 
 §2 
 
 • 
 
 ^ij^T?^y>-4. 
 
 
MEDICAL REPORT 71 
 
 revealed two positives which had been overlooked on 
 first examination. In one, a systematic search through 
 three smears revealed only a single crescent and no 
 other form. Of the cases showing parasites in the blood, 
 the majority presented acute symptoms, that is, chills 
 and fever. The positive cases without fever, were all 
 aestivo-autumnal infections. 
 
 4. Both tertian and aestivo-autumnal infections were 
 found, but no quartan forms. The three cases on the 
 lower Amazon showing parasites in the blood were ex- 
 amples of tertian infection. On the Rio Negro, there 
 were fewer tertian than aestivo-autumnal infections. 
 The one member of our party contracting malaria 
 showed aestivo-autumnal parasites in his blood. Though 
 an aestivo-autumnal infection, he had chills and fever 
 on alternate days, controlled by quinine, but exhibiting 
 the common tendency to recurrence after his return to a 
 temperate climate. 
 
 5. On the Rio Negro, an interesting distribution of 
 malaria was found. Infection is wide-spread on the 
 lower portion of the river, nearly every person being 
 affected. The upper part of the river, on the other 
 hand, is relatively free from malaria. A possible ex- 
 planation of the difference is found in the presence of a 
 steamer line on the lower river by means oi which 
 infected people and mosquitoes are carried from place 
 to place. 
 
72 THE RICE EXPEDITION TO BRAZIL 
 
 Table I. Blood and Spleen Examinations 
 
 
 Blood 
 exam- 
 ination 
 
 Posi- 
 tive 
 
 Nega- 
 tive 
 
 Spleen 
 exam- 
 ination 
 
 Posi- 
 tive 
 
 Nega- 
 tive 
 
 Total 
 num- 
 ber of 
 cases 
 exam- 
 ined 
 
 Monte Alegre, Santarem, and 
 
 Obidos on Lower Amazon. . 
 
 Manaos 
 
 32 
 
 3 
 
 25 
 
 8 
 
 9 
 
 7 
 
 12 
 
 37 
 17 
 
 3 
 
 3 
 
 2 
 
 3 
 3 
 
 29 
 3 
 
 23 
 8 
 9 
 7 
 9 
 
 34 
 17 
 
 8 
 
 20 
 
 20 
 
 7 
 
 9 
 
 6 
 
 16 
 
 30 
 14 
 
 23 
 
 10 
 14 
 
 7 
 
 5 
 13 
 
 16 
 1 
 
 8 
 
 10 
 
 6 
 
 9 
 1 
 3 
 
 14 
 13 
 
 23 
 
 40 
 20 
 
 Barcellos, Lower Rio Negro . . 
 Carvoeiro, Lower Rio Negro . 
 Castanha, Lower Rio Negro . 
 Vista Alegre.Lower Rio Negro 
 San Isabel, Lower Rio Negro 
 Javari, Moura, Providentia, 
 and other places on Lower 
 Rio Negro 
 
 25 
 
 8 
 
 9 
 
 7 
 
 16 
 
 40 
 
 San Gabriel, Upper Rio Negro 
 
 San Jos^ and other places on 
 
 Upper Rio Negro 
 
 17 
 
 23 
 
 
 
 
 153 
 
 11 
 
 139 
 
 153 
 
 66 
 
 87 
 
 204 
 
 Blood, positive (" Parasite rate ") 7.2 % 
 
 Spleen, positive (" Spleen rate ") 43.8 % 
 
 Table XL Differential Blood Counts 
 
 Place Neutrophiles Mononuclears Eosinophiles 
 
 Barcellos, average of 20 cases 41.5 48.5 10 
 
 Lower Rio Negro, average of 20 cases 37.5 46.5 16 
 
 Lower Rio Negro, average of 35 cases 39.0 46.0 15 
 
 San Isabel, average of 10 cases 37.0 50.0 13 
 
 San Gabriel, average of 15 cases 39.0 40.0 21 
 
 Highest Count Lowest Count 
 
 Neutrophiles 68 8 
 
 Mononuclears 75 20 
 
 Eosinophiles 44 1 
 
MEDICAL REPORT 
 
 73 
 
 Splenic Enlargement 
 
 In eighty-eight cases the spleen was examined and 
 found enlarged in fifty-five. There were various degrees 
 of this enlargement, but no case was included under this 
 in which the spleen was not distinctly palpable. There 
 did not seem to be any definite relation between the 
 large spleens and malaria. In the four tertian cases 
 
 .-^i ,,A 
 
 
 j»:-gfcrs.'.fy .gz^. \nmm.-*A- 
 
 Fig. 25. Children with large spleens. 
 Lower Rio Negro. 
 
 the spleen was not palpable, in the four cases of aestivo- 
 autumnal it was large in two and just palpable in two. 
 Some of the spleens examined were huge, larger than 
 any leucaemic cases we have seen, the dullness extend- 
 ing from the mammary line well into the pelvis and con- 
 siderably to the right of the umbilicus. The spleen 
 seemed rather flatter than in leucaemia; in one case the 
 edge could be distinctly grasped through the thin ab- 
 dominal walls and it did not seem to be more than 3 cm. 
 
74 
 
 THE RICE EXPEDITION TO BRAZIL 
 
 in thickness (Fig. 25). There was no difficulty in the 
 determination of the condition, it being necessary in 
 most cases merely to put the hand on the splenic region 
 and in some individuals when standing there was a dis- 
 tinct protuberance of the left side of the abdomen. It 
 was also necessary merel^^ to -question the individuals, 
 
 Fig. 2G. Enlarged spleens in members of the same family. 
 Lower Rio Negro. 
 
 for all except the children were well aware of the con- 
 dition. The spleen as a rule was of intense hardness and 
 rarely tender. It was found both in children and in 
 adults (Fig. 26), the youngest case being four years of 
 age, but there was not opportunity for the examination 
 of very young children. 
 
 All of the cases in which these spleens were found 
 showed a greater or less degree of ill health though most 
 
MEDICAL REPORT 75 
 
 of them pursued their ordinary vocations. They fre- 
 quently complained of constipation, which we thought 
 was possibly attributable to pressure upon the colon. 
 There was also more or less anaemia, but there was 
 nothing in the blood examination to throw light on the 
 condition. All gave a history of malaria (paludismo) 
 at some time in the recent or remote past, but for that 
 matter so does everyone in the country. What is the 
 relation of these huge spleens to malaria, if there be any, 
 we do not know. There was no opportunity for the 
 study of the condition by post mortem examination. 
 As we have known malaria, one of us having had an 
 extensive experience with the disease in Maryland, such 
 spleens are not found. The ordinary condition is a hard 
 pigmented organ, rarely exceeding four hundred grams 
 in weight, and from the apparent size of the spleen in 
 these Rio Negro cases it must frequently have exceeded 
 two thousand grams. Thomas, however, at Manaos, 
 who has seen many of these cases of splenomegaly from 
 the rivers, regards them as malarial and has found often 
 only after the examination of a number of slides, either 
 single organisms or pigment in the leucocytes. He 
 treats the cases with enormous doses of quinine hypo- 
 dermically administered and he thinks with benefit. 
 The same uncertainty is seen in the literature. In the 
 paper of Daniels, " Enlarged Spleens and Malaria" 
 (Thompson, Yates Laboratory Reports, 1901) based or 
 examinations in British Guiana, he says that splenic 
 enlargement is rare though the country is very malarious. 
 His report is valuable as it is based on autopsy records 
 and weights of the spleens are given. Pigmentation of 
 the spleen, which was found in a high percentage of the 
 cases, bore no relation to the size. He refers to obser- 
 vations in Central Africa, where he saw much malaria 
 
76 
 
 THE RICE EXPEDITION TO BRAZIL 
 
 and there enlarged spleen was common in children (50 
 per cent of cases) but he found no enlargement in adults. 
 He suggests that some other factor than malaria is con- 
 cerned in the splenomegaly of malarious districts. We 
 append the valuable table of Daniels. 
 
 Weight of Spleens at Autopsy 
 
 
 East 
 Indies 
 
 N.N. 
 of B. G.i 
 
 Aboriginals 
 of Brit. G. 
 
 Immigrant 
 negroes 
 
 Europeans 
 in Brit. G. 
 
 
 N-P2 
 
 p3 
 
 N-P 
 
 P 
 
 N-P 
 
 P 
 
 N-P 
 
 P 
 
 N-P 
 
 P 
 
 Number of cases .... 
 
 345 
 
 80 
 
 171 
 
 57 
 
 9 
 
 4 
 
 65 
 
 63 
 
 12 
 
 7 
 
 
 % 
 
 % 
 
 % 
 
 % 
 
 % 
 
 % 
 
 % 
 
 % 
 
 % 
 
 % 
 
 Under 150 gr 
 
 4.9 
 
 11.2 
 
 33.9 
 
 35.2 
 
 
 
 46.1 
 
 31.9 
 
 25.5 
 
 
 150-300 gr 
 
 18.5 
 
 32.5 
 
 47.3 
 
 42.6 
 
 22.2 
 
 25 
 
 32.3 
 
 41.2 
 
 41.6 
 
 
 300-450 gr 
 
 24.0 
 
 23.7 
 
 9.9 
 
 14.8 
 
 11.1 
 
 
 6.1 
 
 14.2 
 
 8.3 
 
 57.1 
 
 450-600 gr 
 
 15.6 
 
 20.0 
 
 6.4 
 
 5.5 
 
 22.2 
 
 50 
 
 12.2 
 
 6.3 
 
 16.6 
 
 14.2 
 
 600-750 gr 
 
 12.7 
 
 2.5 
 
 1.2 
 
 
 11.1 
 
 
 
 4.7 
 
 
 14.2 
 
 750-900 gr 
 
 9.8 
 
 2.5 
 
 .58 
 
 
 
 
 
 
 
 14.2 
 
 900-1200 gr 
 
 5.2 
 
 5.0 
 
 .58 
 
 
 
 
 
 1.6 
 
 
 
 1200-1500 gr 
 
 5.5 
 
 
 
 
 
 25 
 
 1.5 
 
 
 
 
 1500-1800 gr 
 
 2.0 
 
 
 
 
 
 
 
 
 
 
 Over 1800 gr 
 
 2.0 
 
 2.5 
 
 
 
 11.1 
 
 
 
 
 
 
 1 Native negroes of British Guiana. ' Non-pigmented. 
 
 Pigmented spleens = malarial spleens. 
 
 ' Pigmented. 
 
 Craig, The Malarial Fevers, 1909, says enlargement 
 during acute attacks is not constant; in most cases the 
 spleen is not palpable. But where the condition is 
 chronic and especially if there have been many relapses, 
 the splenic enlargement is generally noticeable; the 
 organ is palpable and may extend to the umbilicus. In 
 aestivo-autumnal infections a palpable spleen is more 
 often found, and in old infections the spleen is hard 
 and presents a well defined border. Under malarial 
 cachexia he says: " Enlargement of the spleen is a com- 
 mon condition but not an invariable one. I have 
 observed many cases of chronic malarial infection in 
 
MEDICAL REPORT 77 
 
 which the spleen was but little if any enlarged. In old 
 cases the organ may be enormously enlarged, reaching 
 as low as the crest of the ilium, but as a rule it does not 
 extend more than 4-8 cm. below the borders of the ribs. 
 It is firm but not painful on palpation." Deaderick, 
 A Practical Study of Malaria, 1909, says: " The spleen 
 may -be of normal proportions in mild cases but is 
 usually enlarged, sometimes enormously so, passing the 
 median line of the abdomen and the iliac crest. In the 
 malarial cachexia the most pronounced phenomena are 
 the anaemia and the enlarged spleen. The spleen often 
 extends to the umbilicus and to the crest of the ilium, 
 sometimes beyond. It is hard, the anterior border pre- 
 sents a sharp edge and pain and tenderness on pressure 
 are not always felt." He gives a number of photographs 
 of men and boys showing spleens quite comparable to 
 those we saw. 
 
 Stephens and Christophers, " The Relation between 
 the Large Spleen and Parasitic Infection," Reports to 
 the Malarial Committee, Royal Society of London, 1902, 
 reach these conclusions: (1) "A high endemic index 
 (as determined by blood examinations of children) may 
 exist without any appreciative spleen rate (Africa). 
 (2) A high spleen rate may exist in adults without a 
 corresponding parasite infection. (3) In India (Bengal) 
 among children a high spleen rate is a fair index of the 
 parasitic infection. (4) The spleen rate, unlike the 
 parasitic rate, increases up to a certain age limit and 
 may be considerable when the parasite rate is nil." 
 They examined eighty cases in the native hospitals of 
 Calcutta with enlargement of the spleen varying from 
 two or three fingers breadth below the ribs to that of a 
 spleen filling the whole left side of the abdomen and 
 reaching to the pubes. In none of these cases did they 
 
78 THE RICE EXPEDITION TO BRAZIL 
 
 find parasites or pigmented leucocytes or any mono- 
 nuclear increase such as they showed in previous reports 
 to be characteristic of recent infection. In six post 
 mortem examinations on such cases no parasites were 
 found in either spleen or bone marrow. They quote 
 from Plehn, Die Kamerun Kuste, who says that in the 
 majority of the cases examined by him on the Kamerun 
 coast the spleen is not larger than in cases of typhoid 
 seen in Germany, and may be much smaller than this. 
 Annett, Dutton, and Elliot, " Report of Malarial 
 Expedition to Nigeria " (Thompson, Yates Laboratory 
 Reports, 1902) do not mention splenic enlargement as 
 occurring in the natives. Darling, in his studies of the 
 diseases at the Ancon Hospital in Panama, has seen 
 many of these huge spleens, they being known there 
 as the Colombian spleen, and at autopsies he made 
 smears from the spleens. In three cases he found in the 
 greatly enlarged spleen and in the liver numbers of 
 organisms which he described under the name Histo- 
 plasma Capsulatum {Jour. Exper. Med., vol. xi, 1909) 
 and which he thinks differ from the Leishmania of Kala 
 Azar. Two of the cases were Martinique negroes and 
 one a Chinaman who had lived fifteen years on the 
 Isthmus. Darling regards as the main difference be- 
 tween his organism and that of Kala Azar, the absence 
 of the second nucleus. It should be remarked that the 
 presence of this, both in smears and sections of organs 
 may easily be obscured and a comparison of Darling's 
 photographs with sections from typical cases of Kala 
 Azar leaves little doubt in the mind that Darling's 
 cases were really Kala Azar. In the other cases exam- 
 ined Darling found no organisms. Ross, who visited 
 the Isthmus in 1904 and studied the cases of enlarged 
 spleen with reference to the symptom group of Kala 
 
MEDICAL REPORT 79 
 
 Azar, did not find this. In addition to the cases of 
 enlarged spleens which we found on the Rio Negro, we 
 saw great numbers of similar cases in the hospitals of 
 Manaos and Para, particularly in the latter. They came 
 from the upper waters of the rivers and were com- 
 plicated both by ulcers and malaria, but there seemed 
 no interrelation. Although from Darling's report it 
 seems more than probable that certain of these cases 
 may be Kala Azar, this cannot be held to be the com- 
 mon cause. We think that the most of these cases 
 belong to that very obscure condition known as tropical 
 splenomegaly. 
 
 The Upper Rio Negro 
 
 Very different were the conditions found along the 
 upper river about San Isabel. As we have said, the cur- 
 rent is here more rapid, with the exception of certain 
 stretches where the conditions of the lower river are 
 approached, and the banks, islands, and river bed are 
 granite. There is even less population than below, and 
 little pretense to the formation of villages, there being 
 as a rule merely the more or less extensive sitios of the 
 rubber merchants with a few houses of dependents. 
 The population in these places varies depending upon 
 the season of rubber gathering. The extent of country 
 owned or rather controlled by each of the rubber mer- 
 chants and the number of persons employed in rubber 
 gathering varies. The gatherers, seringueros, are chiefly 
 the Indians of the region, who seem to go with the land, 
 and who when weaned from their forest life become 
 practically slaves and totally dependent upon the 
 trader. Rum, which they soon learn to regard as a 
 primal necessity, is the active agent in their reduction 
 to such a condition, but civilization offers other baits as 
 
80 THE RICE EXPEDITION TO BRAZIL 
 
 well, such as small sewing machines, music boxes, etc. 
 Once when travelling on the river with a merchant, a 
 seringuero of wretched appearance, pale and anaemic, 
 presented a list of articles which he wished advanced, 
 such as sugar, coffee, mandioca, etc., but as the poor 
 wretch was already in arrears he was given merely the 
 necessities of life, which consisted of a gallon of rum and 
 
 Fig. 26a. Children at San Gabriel. No splenic enlargement. 
 
 a package of matches. As many as three thousand 
 gatherers may be attached to a single station. 
 
 On this upper river there were seventeen examina- 
 tions of blood, none of them positive. There was little 
 complaint of malaria, although we were told that cases 
 occurred at the end of the rainy season. Mosquitoes we 
 found not at all, although we slept for the most part in 
 native houses, nor in the numerous examinations of the 
 people was there evidence of these having been bitten. 
 The contrast between the populations was striking; on 
 the upper river the people were well nourished and 
 seemingly healthy. The single case of real illness was 
 
MEDICAL REPORT 81 
 
 that of a merchant whose business in collecting rubber 
 led him to take frequent trips below San Isabel and up 
 various rivers. He gave a history of malarial attacks, 
 but the principal trouble seemed cirrhosis of the liver. 
 In thirty -eight cases the spleen was examined and found 
 to be slightly enlarged in one. This was in a child in San 
 Gabriel and was associated with slight enlargement of 
 the liver and slight ascites with no history of malaria. 
 
 The very common condition of enlarged abdomen in 
 the children was very evident and seemed to be due to 
 gaseous distension (Fig. 26a). In this form of disten- 
 sion the thorax is bell shaped, greatly dilated below, due 
 to the thrusting upwards of the abdominal contents, and 
 the liver dullness is not so perceptible as in the normal. 
 
 Mosquitoes 
 
 It seems to us extraordinary that two regions on the 
 same river and presenting such similar physical char- 
 acteristics should so differ in health as the region below 
 and that above San Isabel. It is true that the river 
 below San Isabel is more sluggish with great lake-like 
 expansions often twenty miles or more wide with numer- 
 ous low islands, but above San Isabel there are many 
 such places and the life of the people in the two regions 
 is practically the same. There would seem to be every 
 possible opportunity for the breeding of mosquitoes and 
 the extension of malaria in the two places. There is 
 water in pools formed as the river sinks, water collects 
 from rains in rock depressions, and the irregularities of 
 epiphytic plants holds it; that mosquitoes can breed 
 in such places was shown by our finding numerous 
 embryos in the pot holes in the granite at San Gabriel 
 where we never saw an adult mosquito and where we 
 found no malaria. 
 
82 THE RICE EXPEDITION TO BRAZIL 
 
 The ascent of the Rio Negro to San Isabel was made 
 on a river steamer, we being the only passengers, and 
 the steamer had been completely cleaned for our use. 
 On this we slept without nets, ate on deck and sat there 
 at night, and not a mosquito was seen. On the return 
 from San Isabel on the launch a few mosquitoes were 
 found and one of the party contracted malaria. One of 
 the party returned on the regular river steamer from 
 San Isabel and found very different conditions. This 
 steamer, a larger boat than that on which we ascended, 
 was of shallow draft and propelled by a stern wheel. 
 There were two decks, the lower occupied by the ma- 
 chinery, the crew and the galley, together with freight 
 and the animals carried along to be slaughtered for 
 food. The officers and passengers occupied cabins 
 which ran in a double row in the middle of the upper 
 deck and aft of these the deck was open, giving a space 
 for eating and sitting. The oflBcers and most of the pas- 
 sengers slept in hammocks slung from supports on the 
 upper deck and were not troubled with mosquitoes. 
 The cabins, however, were so filled with them that sleep 
 was impossible. They hid in dark corners and beneath 
 the beds and could not be driven out. They were exclu- 
 sively nocturnal and one could sleep in the cabin during 
 the day without being bitten. The mosquitoes are 
 small, dark in color, and their bites were thickly placed 
 on exposed surfaces, produced little swelling and small 
 areas of hyperaemia and hemorrhage. A well bitten 
 foot and ankle bone has some resemblance to a severe 
 typhus rash. 
 
 After a short stay in Manaos the same steamer was 
 taken for a trip up the Autaz river, which took several 
 days. Here the same conditions were found. The 
 cabins swarmed with mosquitoes but there was little 
 
MEDICAL REPORT 83 
 
 annoyance when sleeping on deck in the open. The 
 beginning of the high water was seen here and large 
 areas of land were flooded. 
 
 No blood examinations were made but some of the 
 people at landings said they had malaria and the popu- 
 lation looked much like that on the lower Rio Negro. 
 Two members of the crew, whose duties involved night 
 work in their cabins, had chronic malaria and in one 
 there was an acute exacerbation. 
 
 The conditions on the upper and lower Rio Negro 
 being so similar, with the exception of the steam trans- 
 portation on the lower river, it occurred to us after 
 experience on the river steamers that this might have 
 some influence on the distribution of disease. The boat 
 makes many stops for wood and at the depots of freight 
 collection and distribution. Nothing goes on with 
 rapidity; the stops are long, the boat often remaining 
 all night alongside the bank and several days are occu- 
 pied at San Isabel. The arrival of the boat is an event, 
 the inhabitants come on board and sit around resting, 
 conversing, and enjoying the alcoholic cheer which the 
 boat provides. The steamer gradually collects mos- 
 quitoes; a few come on board at Manaos and other 
 places and all stay, finding undisturbed abodes in 
 the cabins. Probably every passenger who comes on 
 board, particularly if the night be passed in a cabin, and 
 this is generally the case with the women, becomes in- 
 fected or if so receives a fresh dose. The same is true 
 but to a less extent with the visitors. Whether mosqui- 
 toes breed on the boat is uncertain. The water is taken 
 from the river off the bow of the steamer and pumped 
 into closed iron tanks on the deck roof. The lower deck 
 is usually wet and in the confused mass of machinery, 
 animals, cargo, and crew it would easily be possible for 
 
84 THE RICE EXPEDITION TO BRAZIL 
 
 small pools to form in out of the way places and serve 
 for breeding, but such were not seen. The mosquitoes 
 find abundant food in the humans, in the carcasses of 
 the slaughtered cattle which are hung on the upper 
 deck until used, and in the fruit which is carried. At 
 the landing places the disease may be still further dis- 
 seminated by the freighting canoes and launches which 
 gather to meet the steamer. The prevalence of the 
 disease on the lower river is also favored by the greater 
 population and its collection in villages. 
 
 Diseases of the Indians 
 
 As we have observed the Indians in the hospitals in 
 the Amazonian cities and about the villages on the Rio 
 Negro, there does not seem to be any difference in dis- 
 eases as compared with the whites. Concerning the 
 diseases of the remote forest Indians, we know practi- 
 cally nothing. There have been but few explorers 
 among them, and these have generally been more inter- 
 ested in their own ills than in those of the Indians; 
 usually being devoid of medical training, the descrip- 
 tions of diseases which they have given are of little 
 value. The matter is of great importance, particularly 
 in regard to malaria, for there are Indian tribes in the 
 interior who have never come in contact with whites. 
 Rice, whose exploration of the Uaupes was one of the 
 most carefully conducted expeditions in Brazil, has 
 given some account of the diseases of the forest Indians. 
 (Rice, "River Uaupes," Roy. Geog. Soc. Jour., 35, 1910). 
 He says, regarding the Uaupes Indians, " They are curi- 
 ously free from the most dreaded diseases of civilization, 
 such as cancer, syphilis, and appendicitis. Fever due to 
 malarial infection or simulating such is common, as are 
 large spleens and livers. In the territory of the upper 
 
MEDICAL REPORT 85 
 
 river mosquitoes abound, and rest at night is impossible 
 without nets. On the lower river they are absent for 
 the most part, and infection due to malarial parasites 
 must be transmitted by a host or means other than the 
 anopheles. One case I saw of possible leprosy, and 
 sporadic cases of beriberi are frequent. They are very 
 susceptible to and dread influenza or deflux or catarrho, 
 as it is variously termed. Eye diseases are extremely 
 common, especially conjunctivitis. Infant mortality is 
 high on account of intestinal diseases of protozoan or 
 helminthic origin. Both carate or pinta and eczematous 
 conditions are common. Bronchitis is frequent, due to 
 the Indians' heedless exposure. Rheumatism is notice- 
 ably absent and so is tuberculosis, though with the 
 growth of the rubber industry and the increased inva- 
 sion of the white man, with consequent hybridization 
 will come his two aborigine annihilators, syphilis and 
 tuberculosis." 
 
 In a later exploration, in which he went from Bogota 
 to San Martin and thence through the Northwest 
 Amazon basin along the Inirida and Icana rivers to the 
 Rio Negro, he speaks at more length concerning the dis- 
 eases encountered. San Martin, inhabited by a mixed 
 race of Indian and white, is a centre for the rubber of the 
 district and diseases contracted along the upper waters 
 of the rivers are brought there. He found malarial para- 
 sites in two hundred and fifty examinations of the blood 
 of adults and children. Cariti or pinta was also very 
 common. At San Jose, on the Guaviare, he found fevers 
 and ulcers were common, and also a peculiar and painful 
 disease of the toes, locally called sabauones. This 
 begins with intense itching, especially between the toes, 
 and a slight colorless exudate of foul odor. The skin 
 turns white, sloughs off, acute inflammation ensues, and 
 
86 THE RICE EXPEDITION TO BRAZIL 
 
 the underlying tissue becomes pulpy. Any attempt to 
 move the foot or even stand on it is productive of a most 
 intense and unbearable pain. At Calamar he found the 
 majority of the people ill, and he himself acquired a 
 tropical ulcer, the cicatrix of which is shown (Fig. 31). 
 On the Papunaua, a black water stream by which he 
 passed from the Inirida to the Icana river, he found, 
 much disease among the Indians and the blood invari- 
 ably showed tertian malarial organisms. The Icana 
 would seem to be a much healthier stream than the 
 Inirida and he makes no mention of diseases encoun- 
 tered here. It is interesting that he found malaria in 
 the maloccas of tribes which had no outside contact, but 
 the possibility of carriers could not well be excluded. 
 He says nothing here in regard to splenic enlargement. 
 
 Chandless (" Exploration of the Purus," Roy. Geog. 
 Soc. Jour., 36, 1866) speaks of the great seasonal varia- 
 tion in health along this river. At the period of his 
 exploration it was healthy, but eight years previously 
 it was very unhealthy. He mentions a form of skin 
 disease as common among the Indians, but gives no 
 description of it. He says that Indians of other tribes 
 have caught it and one white man, but it is not commun- 
 icated by ordinary contact. 
 
 Whiffin (The Northivest Amazon, 1908) has made a 
 careful study of the remote Indians, and naturally this 
 embraces something of their diseases and medical prac- 
 tices. These Indians are cowards in sickness, believing 
 it is due not to natural causes, but to charms and poison- 
 ings. Poisoning is common. Should an infectious dis- 
 ease appear, those attacked are abandoned. Malarial 
 fevers are common, chest diseases rare, and respiratory 
 diseases unknown. There is also no venereal disease. 
 Lice are universal; ring-worm and intestinal parasites 
 
MEDICAL REPORT 87 
 
 are very common troubles, and chiggoes, always found 
 in the houses, are a great pest. Regions have been 
 devastated by smallpox, which was introduced by the 
 rubber gatherers. Beriberi does not attack Indians, but 
 pinta is not uncommon. Small families are the rule, 
 children are not born frequently, two and a half years 
 being the average between births, and the infant mor- 
 tality is high. Twin births and congenital deformities 
 are said to be unknown. These would be regarded as 
 disgraceful, as simulating conditions which may be 
 found in animals, and their absence may be due to the 
 habit of washing the child immediately after birth, in 
 the river, giving facility for losing an undesirable family 
 connection. 
 
 Fawcett (" Explorations in Bolivia," Roy. Geog. Soc. 
 Jour., 35, 1910) found many interesting conditions in the 
 country travelled, but says little about the diseases of 
 the Indians. Espundia, an ulcerous sore difficult to 
 heal and said to be due to the scratching of insect bites, 
 was frequently encountered. The virus of this may be 
 carried to the nose, causing sloughing of the cartilage. 
 He also mentions the great variation in the sickness 
 along the rivers in different years. 
 
 It is not impossible that there are preserved some- 
 where in the reports from the old Jesuit missions, which 
 were scattered everywhere through the country, inter- 
 esting and accurate descriptions of the Indians before 
 the trader came into contact with them. The great 
 explorers of the preceding century, Humboldt, Spix, and 
 Martins, Wallace, Spruce, and Bates, have little or 
 nothing on the subject of Indian diseases.^ The condi- 
 tions shown in the very meagre information we have are 
 
 ^ Martius, however, has given a very graphic description of the ravages 
 of smallpox which he encountered on the Peruvian border. 
 
88 
 
 THE RICE EXPEDITION TO BRAZIL 
 
 about what we might expect. We should expect the 
 incidence of malaria, especially in the latent and chronic 
 forms, to be high, for the life of the Indians would favor 
 it. The common house or malocca certainly offers ideal 
 conditions, in facilities for harboring anopheles and 
 there must be sufficient intercourse to give some of 
 these a chance for infection. 
 
 Although reliable statistics are absent, there seems no 
 doubt of a great diminution in the numbers of the Indian 
 
 '" ' J '1 
 
 ■:.>-J i" 
 
 
 
 :^^^ 
 
 ^^^ 
 
 ft 
 
 ■ -"^-„|g^ 
 
 Fig. 27. Paralytic form of Beriberi. 
 Iquitos. 
 
 population. There have been many factors in the dim- 
 inution, but disease, particularly smallpox, has probably 
 been the most important. To the factor of disease must 
 be added inter-tribal wars, which were encouraged by the 
 whites with the view of procuring slaves from the victors. 
 The commercial exploitation at the present time, which 
 increases alcoholism, breaks up the family life, and by 
 increasing intercourse gives greater opportunity for the 
 extension of infection, plays an important part in exter- 
 mination. The Indians are without protection, practi- 
 cally at the mercy of a commercial people in whom the 
 traditions of the exploitation of weaker peoples are 
 firmly fixed. It would seem that man can always be 
 trusted to kill the goose which lays the golden egg. 
 
MEDICAL REPORT 89 
 
 Leprosy 
 
 This is undoubtedly a wide-spread disease in the 
 region, but how extensive there is no means of knowing. 
 There are leper asylums attached to the cities and the 
 principal towns, but there is no pretense to strict seg- 
 regation. The cases we saw were of the ordinary 
 tubercular and mutilating forms. 
 
 Beriberi 
 
 But one case of this (Fig. 27) a well marked paralytic 
 form, was seen in the hospital at Iquitos. If this is a 
 disease dependent upon food conditions the variety of 
 food and the large use of fruit would seem not to favor 
 it. 
 
 Yaws and other Forms of Skin Diseases 
 
 We saw no cases which were diagnosed as yaws and 
 no cases which we recognized as this, but it might readily 
 have been overlooked. Pian was not uncommon both 
 in the hospital cases and along the rivers. There were 
 a number of cases of skin disease, the diagnosis of which 
 we could not determine. 
 
 FiLARIASIS 
 
 In spite of the frequency of elephantiasis in Rio and 
 the southern states of Brazil we saw in the Amazonas no 
 cases either in the hospitals or among the people. We 
 do not know whether there have been any systematic 
 blood examinations to determine the absence of filariasis. 
 
 Other Diseases 
 
 At San Isabel we saw one typical case of acromegaly 
 in a mulatto. 
 
90 THE RICE EXPEDITION TO BRAZIL 
 
 Ulcers 
 
 One of the most common conditions found in the 
 hospitals of Para, Manaos, and Iquitos, were ulcers, 
 usually on the lower extremities and varying in extent 
 and character. The ulcer patients form a large per- 
 centage of the hospital cases and generally come from 
 the head waters of the rivers, most of those in Manaos 
 from the Madeira. The subjects were usually badly 
 nourished, anaemic, and had in addition malaria, and 
 the huge spleens common to these regions. The spleens 
 were particularly noticeable in the ulcer ward in Para. 
 
 These ulcers have of late acquired a greater interest, 
 due to the discovery in them of Leishmania, which 
 places them in the category of the Button of the Orient. 
 There is an extensive literature on the subject, most of 
 which is contained in the Bulletins of the French Society 
 of Tropical Medicine. The specific character of cer- 
 tain of these ulcers and the organisms associated with 
 them were first noticed among the railroad workmen in 
 Bauru, a town in the western part of San Paulo, the 
 most southerly state of Brazil. Lindenberg {Bull, de la 
 soc. de path, exot., vol. ii, 1909) describes the ulcers as 
 occurring chiefly on parts of the body which are uncov- 
 ered. The ulcers are round or oval, sharply cut, with 
 projected edges of a deep violet color, the base covered 
 with deep vascular vegetations or with an adherent 
 crust. Sections of the old ulcers showed nothing, but 
 in one case in which there were several small ulcers 
 1.5 cm. in diameter and of one month duration, the sec- 
 tions showed the organisms first described by Wright, 
 and in scrapings from other ulcers the same organisms 
 were found. In 1895 Moreira described similar ulcers in 
 Bahai, but did not recognize the parasite. Lindenberg's 
 
MEDICAL REPORT 91 
 
 results were confirmed in a following article by Carini 
 and Paranhos, who think the disease follows the prick 
 of an insect and appears first as a papule which later 
 develops into an ulcer and becomes covered with a thick 
 crust. Carini and Splendore in the same journal, 1911 
 and 1912, describe ulcers on the mucous membrane of 
 the nose and hard palate, which follow the ulcers of the 
 skin. In Carini's case "the surface of the palate was 
 ulcerated, the ulcer covered with irregular, prominent, 
 firm granulations. There were also erosions covered 
 with an adherent yellow exudate. The uvula was 
 destroyed, and its place taken by a granulating surface. 
 On the inner surface of the left nostril there was an 
 oedematous swelling covered by a thick crust which 
 almost occluded the nostril. Various travellers in Peru 
 have spoken of similar ulcers of the mouth and nose, 
 known there under the name of Espundia, and Escomel 
 (Bull, de la soc. de 'path, exot., 1911) gives a full descrip- 
 tion of the disease. It follows after a variable time, 
 which may be months or years, the ulcers on the skin, 
 which he regards as the chancre or initial lesion. He 
 found no organisms but in excised areas from the palatal 
 lesions which he sent Lavaran the latter found Leish- 
 mania both free and enclosed in cells. The organisms 
 are round, of the same size as the Leishmania, have a 
 nucleus and centrosome, but differ from the Leishmania 
 of Oriental Button in that the nucleus is flattened and 
 closely applied to the wall. The organism was present 
 in very small numbers and he regards it as a variety of 
 the Leishmania tropica. In other parts of Peru the 
 condition is known as Uta and material from these cases 
 was studied by the expedition to Peru carried out by 
 the Harvard Department of Tropical Medicine in 1913, 
 and the organisms in small numbers were found both 
 
92 THE RICE EXPEDITION TO BRAZIL 
 
 in smears and sections: (" Report of the First Expedi- 
 tion to South America, 1913"). Similar conditions have 
 been described in other parts of Brazil, in Peru, in Para- 
 guay, and on the Isthmus. The Espundia is well known, 
 not only in Peru, but in Bolivia, Ecuador, and Colom- 
 bia. The best clinical description of the ulcers is that 
 given by Matta of Manaos {Bull, de la soc. de path, 
 exot, vol. ix, 1916). " The ulcer begins with itching of 
 the part, followed by elevated papules. Two to five 
 days afterward small pustules, in size from the head of 
 a pin to that of a grain of wheat form, which rupture 
 and discharge a purulent yellowish gelatinous material. 
 The small ulcers so formed extend by infection of the 
 surrounding surface, by the secretion, and also by 
 means of the lymphatics. The ulcer becomes covered 
 by a crust, beneath which a quantity of intensely foetid 
 pus is retained. On removing the crust there appears a 
 deep ulcer with projecting edges. Cases rarely recover 
 spontaneously, leaving large permanent cicatrices." On 
 one patient Matta found fifty-one lesions which exhib- 
 ited every phase of development up to cicatrization. 
 
 There is a general inclination to attribute the cause to 
 insect bites, and all the common insects with the excep- 
 tion of the mosquito have been accused in turn. Where 
 there is a prominent and disagreeable insect in a region 
 and ulcers at the same time are common, the additional 
 burden of the ulcers is loaded upon the shoulders of the 
 insect. It has been given a great variety of local names 
 and is generally recognized by the common people as a 
 definite disease. It occurs most generally in the virgin 
 forests of the upper sources of the rivers, though cases 
 occur in the vicinity of Para and Manaos. It is partic- 
 ularly common among the rubber gatherers who are 
 most exposed to insect bites, have chronic malaria, are 
 
MEDICAL REPORT 
 
 93 
 
 badly nourished, and live miserably in the forest. One 
 point always alleged in favor of insect transmission is 
 the occurrence of the ulcers on uncovered parts of the 
 body, but it should be remembered that these parts are 
 
 Fig. 28. Leishmania ulcer of the 
 Oriental Button type. Manaos. 
 
 most subject to traumas of all sorts. The skin in the 
 tropics, owing to the constant maceration with sweat, 
 is not so perfectly protected by the horny layer of epider- 
 mis, and owing to the scratching of insect bites, erosions 
 which easily become superficial ulcers arise. There are 
 mild forms which closely resemble the Oriental Button 
 and which easily recover, and severe intractable forms. 
 
94 
 
 THE RICE EXPEDITION TO BRAZIL 
 
 The most intractable forms are those in which the 
 mucous membranes are attacked and the disease may 
 extend from the palate to the pharynx and larynx, 
 leading to death. Similar ulcers have been found in 
 dogs. 
 
 Vianna (Arch. hraz. de Med., Anno II), quoted from 
 Carini, led by the good results of tartar emetic treat- 
 ment in trypanosomiasis, was the 
 first to try this remedy here. He 
 obtained good results and it has 
 become the accepted mode of 
 treatment. This is administered 
 intravenously in doses of 5 to 
 10 c.c. of a 1 per cent solution. 
 
 Of the ulcers we saw in the 
 hospitals there were a number 
 which corresponded with the de- 
 scriptions given of these specific 
 ulcers. They could be classed 
 under three heads. First, ulcers 
 which were usually single, with 
 firm elevated oedematous borders, 
 sharp in outline, the entire ulcer 
 elevated and covered with a firm 
 adherent crust. The type of these 
 is given in Figs. 28, 29, that of the second case being a 
 healed ulcer of the scalp. These cases are very similar 
 to the Oriental Button, which, however, does not occur 
 on the scalp. In the second class the ulcers, single or 
 multiple, are usually situated on the extremities, the 
 edges are sharp and irregular, the base covered with soft 
 projecting granulations. The ulcers extend laterally, 
 but chiefly by the formation of foci in the adjoining 
 tissue, which coalesce, giving rise to large ulcers with 
 
 Fig. 29. Cicatrix ox scalp 
 
 followixg ulcer of the 
 
 TYPE OF Oriental 
 
 Button 
 
MEDICAL REPORT 
 
 95 
 
 great irregularity of outline (Fig. 30) . The ulcers often 
 heal spontaneously, leaving thin parchment-like cica- 
 trices. 
 
 This character of cicatrix was very evident in that 
 resulting from a large ulcer on the anterior tibia which 
 
 Fig. 30. A group of Leishmania ulcers. Manaos. 
 
 had been contracted in an exploration on the Uaupes 
 river (Fig. 31). The outline was irregular and the entire 
 cicatrix was thin, parchment-like, of a pale blue grey 
 color, with superficial tortuous veins. There was a 
 marked tendency to breaking down of the cicatrix under 
 slight traumas. The third type is that in which the 
 mucous membrane of the nose or palate is involved and 
 which may accompany or follow the skin forms. In 
 certain cases a skin ulcer of the face may extend to 
 
96 
 
 THE RICE EXPEDITION TO BRAZIL 
 
 an adjoining mucous membrane, and in certain cases 
 the mucous membrane seems to be affected primarily. 
 These cases seemed to heal up rapidly under the anti- 
 mony treatment. 
 
 Histologically the ulcers differ in a marked degree 
 from typical cases of Oriental Button, in the absence 
 
 Fig. 31. Cicatrix on leg the result of 
 Leishmania ulcer. The cicatrix is thin, 
 parchment-like, the edge irregular, no con- 
 TRACTION EXTENDING FROM CICATRIX. ThE 
 UNDERLYING TISSUE HARD AND ANAEMIC. 
 
 of the great numbers of large phagocytic cells containing 
 the Leishmania. The granulation tissue is not very 
 vascular; there is marked thickening of the walls of the 
 vessels by proliferation of endothelial cells and active 
 migration of leucocytes. The general tissue is oedema- 
 tous, the oedema extending well beneath the adjoining 
 
MEDICAL REPORT 97 
 
 epidermis, and foci of fibrin are found in it. The pre- 
 vailing cells are of the plasma type and these are both 
 collected in groups and generally infiltrated. The sur- 
 face is covered with pus cells and a thin layer of fibrin. 
 The epidermic edge of the ulcer proliferates extending 
 over the surface and sending deep prolongations into 
 the oedematous granulations, but the cells are separated 
 by an intercellular oedema and become necrotic. The 
 
 
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 ■s '»■: ' •• 
 
 « • ■ --'^ : ' ■• ^" ."■'•..•' • .■'■ • 
 
 Vv . . * 
 
 - ' : /^ •,- > :. • .-. ;. 
 
 > '. * ' ^ i ■ 
 
 
 
 ■%1*y'/- ■■ '■ '*' ' ° :■ , V- ■ 'W^c,' 
 
 ^..^^. ^■ . .. 
 
 
 ■'•im\ *" ' ^ * " 
 
 ■ -• . ■' ' ■■' '. . " ■ r ■' ^ ■" * .'■• ■' V ' •.-' :'■' "•" ' < 
 
 N'^*-; ■ ■ . , . . 
 
 '•, '••'■'^'<A.-^:-'--' r:.y. '}■■/ •■,-,■■-•■' ^v^,-'. t!""^. • 
 
 l". '. ^■' _ ' -. 
 
 
 VV ;"".,;' /: ■ ■' .: 
 
 ' • ->' •■•<•-■■ J?'"'t- ■'.:•;•. ■-'•". ^ ■■.;•.'• ■-" • '^.- ■ ' 'v .'.■'• : . -'■-'" 
 
 
 
 •c" i/" '. .: '^ " ; . 
 
 ■ '•'*f--W^".'-."^.V:-.''x,V. './;'•' ." ••:-•.• :A-<'-Y'r--x:>' 
 
 Fig. 32. Low poweh drawing of section of LEISHMA^^A ulcer 
 
 SHOWING OEDEMATOVS TISSUE AND ENDOTHELIAL PROLIFERATION. 
 
 same process takes place in the sweat glands. There is 
 but little proliferation of the connective tissue and an 
 entire absence of the dense, newly formed connective 
 tissue which covers the base of our common ulcus 
 crunis (Fig. 32). 
 
 All observers agree in the great rarity of Leishmania 
 in the ulcers. They are chiefly on the surface and more 
 readily found in smears than in sections. In the older 
 ulcers, with marked suppuration, they are generally 
 absent. We made a number of smears from the ulcers 
 in Para and in Manaos, and were not able to find 
 
98 THE RICE EXPEDITION TO BRAZIL 
 
 organisms in any of them. These smears were stained 
 after we returned, and were overgrown with fungi and 
 in bad condition. We also brought pieces removed from 
 a number of ulcers in securing which not much choice 
 was possible and several of them were evidently from 
 ulcers of a different character, or of a chronic type. In 
 two cases only, of recent ulcers in which the oedema 
 and indolent character were marked, were organisms 
 found, and that after a prolonged search. They were 
 
 both free and intracellular and 
 chiefly on and immediately 
 beneath the surface. They 
 each showed the character- 
 istic trophonucleus and the 
 punctiform kineto nucleus 
 opposite. The accompanying 
 ilhistration is made from a 
 Fig. 33. Leishmania from skctch by Profcssor E. E. 
 SURFACE OF ULCER. Tyzzcr (Fig. 33). We were 
 
 not able to secure sections from the ulcer on the fore- 
 head which closely simulated the Oriental Button. 
 
 Certain of the large deep ulcers which we saw simulate 
 the simple tropical ulcers and the sections corresponded 
 with the histology of those which were studied by Dr. 
 Wolbach and which are probably due to spirochaetae. 
 
 On the whole it seems to us evident that there are in 
 this region ulcers due to a variety of causes. Some of 
 them correspond to the type generally referred to as 
 tropical ulcer, the most probable causative organism 
 being spirochaetae. There are other ulcers, due to a 
 combination of trauma and general malnutrition (Fig. 
 34). We saw two cases in which the ulcers were epider- 
 moid carcinomas. Syphilis in all forms is common and 
 some of the ulcers are probably due to this. It is very 
 
MEDICAL REPORT 
 
 99 
 
 probable that yaws prevails in the region, and some of 
 the ulcers may have been due to this. Among the many 
 names of the Leishmania ulcers is that of " forest 
 yaws." We saw, however, no cases of yaws, at least 
 none so diagnosed. We did not see the types of varicose 
 ulcers which are so common here. There are other 
 ulcers of a true specific character, due to Leishmania 
 
 Fig. 34. Section of ulcer of indetekmixate type. 
 Compare with Fig. 30. 
 
 and which have definite clinical and histological char- 
 acteristics. The thorough differentiation of all these 
 types of ulcers is not possible with the facilities which 
 the hospitals offer. It is by no means certain that a 
 careful study of the ulcers in our country, particularly 
 in the south, will not show the Leishmania form here. 
 
 Conclusions 
 
 No one can come into even superficial contact with 
 this vast region without having his imagination stirred 
 
100 THE RICE EXPEDITION TO BRAZIL 
 
 by the thought of what the future may bring forth.^ Up 
 to the present it is a virgin land on which man's efforts 
 have made no impression, and he has not turned the 
 natural forces to his advantage. He has to a limited 
 extent lived in the region by utilizing some of the pro- 
 ducts which nature so abundantly provides. Some of 
 these are used directly and for sustenance, others are 
 used indirectly and as objects of barter. The most 
 prominent example of the latter is rubber and there can 
 be little doubt that its exploitation has been a terrible 
 calamity to the native inhabitants of the country. How 
 great this calamity has been, in the destruction and 
 degradation of the Indian population, we have no accur- 
 ate information, but all we are able to learn shows that 
 it must have been very great. Of the other strictly 
 forest products nuts come next in value, but owing to 
 their bulk and small value, these can never be exploited 
 to the same degree. 
 
 ^ Humboldt saw a glorious vision of the future with the utilization by 
 commerce of the incomparable system of waterways. There is water com- 
 munication everywhere, throughout the valley, extending into Bolivia, 
 Peru, Ecuador, and Colombia, which could be easily made available for 
 light draught steamers. Venezuela and the Argentine could be reached, 
 the former by the Cassiquiare Canal and the latter by the construction of 
 an eighteen-mile canal between the head waters of the Tapajos and the 
 Paraguay rivers. Great interest in the region was excited in our country 
 by the glowing articles of M. P. Maury, the eminent oceanographer, 
 in the National Intelligencer, which were afterwards published in pam- 
 phlet form, 1853. The exploring expeditions of Herndon and Gibbon, 
 sent out by the United States Government, going into the valley from 
 the west, the former descending the Huallaga and the latter passing 
 from Peru into Bolivia and descending the Madeira, added to the interest. 
 Both of these expeditions were well organized, well conducted and pro- 
 ductive of much information regarding the physical features, and the 
 products of the land. The immediate object was to obtain concessions 
 from the governments for steamboat navigation, but it is not improb- 
 able that the ulterior but more important object was to discover whether 
 the country was a suitable one for emigration with the extension of 
 slavery. 
 
MEDICAL REPORT 101 
 
 There are present throughout the region three con- 
 ditions which are most favorable for growth; heat, 
 abundant moisture, and a fertile soil ; and the growth is 
 prodigal. At Para there is a silk cotton tree in the 
 grounds of the museum five feet in diameter above the 
 buttress, which has grown to this size in nineteen 
 years from the seed. At Umarituba there is a Brazil 
 nut tree forty feet high which was planted as a sapling 
 five years before. Rubber trees grow readily from seed 
 and can be tapped in fifteen years and the two principal 
 nut trees begin to bear in eight years. A still more 
 remarkable example of rapidity of growth was seen in 
 the forest at San Isabel. An immense tree in full vigor 
 had fallen at some recent period for the dried leaves 
 were still retained on the branches. The fall of such a 
 tree leaves a definite hole in the forest roof which was 
 occupied by its crown, yet at the time we were there the 
 roof, by the extension of the adjoining trees, had closed 
 up again. The bishop of Santarem told us that he 
 obtained three crops of grapes yearly from the vines in 
 his garden, and three crops of corn also can be obtained 
 in the same year. When the forest is removed and the 
 land pastured it produces an abundant, even luxurious, 
 fine grass which is very nutritious ; cattle are fat and the 
 pastures seem to support a large number to the area, in 
 one place we thought about one and a half cows to the 
 acre. The great wealth of the land is in the forest which 
 covers it and up to the present this has not been touched, 
 no means having been found for its commercial exploi- 
 tation. Bates in 1850 speaks of the great difficulty he 
 found in procuring boards out of which to construct 
 boxes for his specimens, and the boxes in which the 
 rubber is packed up to three years ago were made of 
 
102 THE RICE EXPEDITION TO BRAZIL 
 
 imported pine lumber. The forest undoubtedly will be 
 utilized but probably only through cooperative effort 
 and on a large scale. A great part of the country, the 
 entire igapo and varzea region, lies so low that the 
 annual floods will prevent the utilization of the land for 
 other than forest culture, and with the selection of the 
 most desirable and profitable varieties of trees the in- 
 credible rapidity of growth should ensure a frequent and 
 abundant harvest. The food provided by the waters 
 is great in amount and excellent in quality and there 
 would seem to be no doubt that the region is capable of 
 the support of a vast population and that through the 
 utilization of its surplus product by sale and barter great 
 wealth should flow into it. 
 
 The first thing to be ascertained, however, is whether 
 the country is a possible or a desirable place for man to 
 live in. Although all information regarding the natural 
 resources and agricultural possibilities is lacking in 
 scientific accuracy, the food supply seems to be sure, but 
 man needs something more. There must be a possi- 
 bility of life with the attainment of some degree of that 
 moral and mental well-being which we are accustomed 
 to associate with the idea of happiness. This would 
 seem to involve not too laborious a life, opportunity for 
 the cultivation of the mind and aesthetic sense, reason- 
 able freedom from pain and disease and a physical envir- 
 onment which would not produce constant discomfort. 
 Scientific, accurate information regarding the diseases 
 of the region is not obtainable. We have only the health 
 reports which are published in the cities and the very 
 meagre information to be obtained from travellers 
 and explorers, and the most valuable part of the latter 
 relates to the persons involved. We have appended to 
 the description of our visits to the cities the statistical 
 
MEDICAL REPORT 103 
 
 information coming from the health authorities. These 
 reports have seemed to us from comparison with health 
 reports elsewhere and from what we have seen in the 
 way of lack of facilities for diagnosis and general lack 
 of accuracy where disease is concerned, to be grossly 
 inaccurate. It is impossible to ascertain the death rate, 
 for the population is merely conjectured and it is not at 
 all certain that all deaths are reported. There are cer- 
 tain things in the reports which seem obviously wrong, 
 as the large number of deaths from malaria and the 
 almost total absence of tuberculous meningitis as a cause 
 of death. In 1909 in Para there were 1159 deaths from 
 malaria, and taking the average mortality of 2.89 per 
 cent, this would give 40,100 cases or one to every four 
 and a half inhabitants, which would certainly seem ex- 
 cessive. In one respect the reports certainly agree with 
 what we have seen, that is the small part which malig- 
 nant tumors play as a cause of death. We never saw in 
 the hospitals or elsewhere a single case of cancer of the 
 breast or of the face. The only cutaneous cancers we 
 saw were those associated with ulcers on the legs and 
 other traumas. Two cases of sarcoma were seen; no 
 cases of Hodgkin's disease, and even the simple tumors 
 seemed to be rare. While many of the internal cancers 
 would be likely to elude diagnosis, those on the surface 
 are obvious. Were the internal cancers common but not 
 recognized, they would cause a greater mortality in the 
 diseases of the alimentary canal, which, however, pl^y a 
 relatively small part in the statistics. We think we are 
 justified in saying that malignant tumors are rare as 
 compared with temperate climates. The statistics are 
 moreover lacking in information relative to age at death. 
 In regard to the health of travellers and explorers, 
 many who were not at all acclimated or accustomed to 
 
104 THE RICE EXPEDITION TO BRAZIL 
 
 the life of the country and most of whom did not make 
 use of precautions which we would now regard as essen- 
 tial, lived in the country without much disability from 
 sickness and without any permanent impairment of 
 health. Humboldt had several attacks of fever during 
 his stay but lived to an old age. Both Spix and Martins 
 suffered from fevers and the early death of Spix may 
 have been partly due to the illness which he underwent 
 here. Bates also had attacks of malaria and probably 
 dysentery, but attained old age. Spruce had the same 
 experience and seems finally to have died of chronic 
 ulceration of the rectum, probably the result of dysen- 
 tery. The brother of Wallace died of yellow fever in 
 Para, and the naturalist, though several times attacked 
 with fever while in the country, died but a few years ago. 
 Chandless had fever and indeed this seems to have been 
 an almost universal experience, although no mention of 
 it is made in Mrs. Agassiz' account of the Agassiz 
 expedition. Bismarck does not seem to have undergone 
 any loss of vigor in consequence of the year spent here 
 as a member of the expedition of Prince Adalbert. Rice, 
 using modern precautions, on the Uaupes escaped mala- 
 ria but acquired tropical ulcer. Smith was the most 
 fortunate. During a residence of four years in the coun- 
 try, before prophylaxis was known, he escaped malaria 
 but on his return to the United States acquired the 
 disease after two weeks' residence in Ohio. There is an 
 interesting circumstance regarding malaria which comes 
 out prominently in all the accounts of the old explorers. 
 In the ascent of rivers all would go well until the upper 
 waters and the rapids were reached. Food was here less 
 abundant, the work of pushing up the boats arduous, 
 the men were continually wet from work in the water 
 and constant rains, and fever would usually appear, 
 
MEDICAL REPORT 105 
 
 which is easily understood if we assume that the crew 
 already had the disease in latent form. It is not improb- 
 able that some of the severe fevers encountered were 
 yellow fever and not malaria. 
 
 Catarrhal conditions of the respiratory mucous mem- 
 branes as evidenced in coughing, hawking and spitting, 
 seem to be common, although severe infections of the 
 parts are rare. On the steamers it is not uncommon to 
 see a pool of expectoration beneath the hammock. How 
 much this unpleasant feature is merely a habit or how 
 much due to conditions induced by constantly smoking 
 the irritating tobacco of the country is uncertain. That 
 it is not seen among the foreigners is in favor of its 
 being merely a habit. The health of our party was 
 good throughout, the only exception being a not severe 
 case of aestivo-autumnal infection acquired during the 
 descent of the Rio Negro by one of the writers who was 
 somewhat careless both in regard to prophylactic 
 quinine and mosquito net. 
 
 The health of the crew of the yacht was good during 
 the entire expedition. They were on the whole young 
 men of good physique and, with the exception of the 
 officers, represented many nationalities. The yacht 
 with the crew remained at Manaos for the three months 
 of the Rio Negro expedition. Shore leave was freely 
 granted and games on shore were arranged for them. 
 The food was more than ample and no change was made 
 from that to which they were accustomed. There were a 
 number of cases of venereal infection acquired at about 
 every port, chiefly of course at Manaos. There were no 
 cases of malaria or dysentery. There was one case of 
 continued fever which lasted for four weeks, part of 
 which time was spent on shore in the hospital. The 
 nature of this was not ascertained, but it seemed from 
 
106 THE RICE EXPEDITION TO BRAZIL 
 
 its course to have been a mild case of typhoid, although 
 at the time there was said to be no typhoid in the 
 city. 
 
 There are many foreigners in the cities, and so far as 
 we could see these lead lives anything but hygienic, and 
 the amount of alcohol consumed is enormous. The 
 drink habit seems to be extended in the region, involving 
 practically all who can obtain alcohol. Of course noth- 
 ing definite could be found out regarding the effect of 
 the climate and the alcohol on the duration of life, but as 
 far as cursory observation and information given by 
 physicians and others enabled us to judge, the people 
 stood the alcohol just about as well as they would have 
 in another environment. It has seemed to us if we 
 selected the one disease of the region to which the 
 greatest degree of physical degeneration is due and 
 which indirectly furnishes the underlying cause of many 
 infections, it is alcoholism. Venereal diseases, partic- 
 ularly^ syphilis, are prevalent. It will be observed that 
 they do not enter at all into the causes of death in Pard 
 and to a slight extent only in Manaos. Our statement 
 regarding this comes from observation and from infor- 
 mation gathered. from physicians. We have never seen 
 prostitution more open and more repulsive than in 
 Manaos, and advanced cases of syphilis are not infre- 
 quently seen. It would be very interesting to get the 
 Wasserman test of the entire city of Manaos. On the 
 whole, as far as concerns health and food, there is no 
 difficulty about living in the country. The greatest 
 danger comes from malaria and with the ordinary 
 precautions this can be avoided as well here as in any 
 region where the disease prevails. 
 
 Probably the greatest bar to settlement of the country 
 is not its diseases but the insects. In a locality infested 
 
MEDICAL REPORT 107 
 
 with piums and micuims life is hardly endurable, but 
 the former are confined to river banks in certain definite 
 localities and the latter to the pastures and may be 
 avoided. They are absent in all houses, cultivated lands 
 and paths which are kept free from grass. The pest of 
 ants is a minor detail and one easily guarded against. 
 There is one condition which we have not seen men- 
 tioned as pertaining to tropical life, and that is a greater 
 vulnerability of the surface of the body. Small abra- 
 sions and wounds of the surface easily occur, giving 
 possibilities of infection. It seemed to us this was due 
 to thinning of the epidermis by the maceration of sweat 
 combined with frequent bathing. Scratching of insect 
 bites is particularly to be avoided. While scratching an 
 itching surface gives a pleasurable sensation, the denial 
 of this pleasure will lead to physical and probably 
 moral betterment. 
 
 Apart from all these things is the country fit to live 
 in ? In regard to the effect of tropical temperature on 
 the life of the white man the data at hand are not suffi- 
 cient for us to know much. The prevailing temperature 
 of the region is undoubtedly high and remarkably even, 
 probably about eighty or slightly above is the average 
 temperature of the valley. There may be extremes of 
 ninety-five and sixty-four; we saw 71° Fahr. at San 
 Gabriel once at the end of a violent rainstorm and 
 68° Fahr. on the lower river after a storm. It seems 
 to have been shown that the greatest mental and 
 bodily activity of man coincides not with an even, but 
 an irregular temperature. The experience at Panama 
 has shown that the white man can undergo hard physi- 
 cal labor in a high temperature and preserve his physical 
 well-being, but the test has not been long enough to 
 show what would be the effect of continuous residence. 
 
108 THE RICE EXPEDITION TO BRAZIL 
 
 The writers were not conscious of any loss of energy and 
 of general well-being when in the country save that due 
 to a malarial attack in one of us. The machinery of the 
 body becomes adjusted to the continuous high tempera- 
 ture, blankets are comfortable at night, and a drop of 
 temperature to 70° Fahr. entails real discomfort. The 
 eyes also become accustomed to the intensity of light, 
 which at first is disagreeable, and shaded glasses become 
 unnecessary. We did not find such intensity of light in 
 the region as in the West Indies, which is probably due 
 to the amount of moisture in the atmosphere and the 
 blanket of clouds. The most intense light was given 
 when the sunlight at midday was reflected from great 
 cumulus clouds near the zenith. The time necessary 
 for photographic exposures was not greatly shortened. 
 Nights are always cool, giving opportunities for reading 
 and refreshing sleep. Certainly the work accomplished 
 by the naturalists who lived in the country shows no 
 lack of mental and physical vigor. This is, however, an 
 unfair comparison, for these men represented a highly 
 selected material who had work to do and an incitement 
 to work which does not come from mere living. Whether 
 the white man in the tropics will expend force beyond 
 that which is necessary for mere living is uncertain, and 
 the probability is that he will strive to lessen even such 
 endeavor by compelling others to work for him. It must 
 be said that up to the present white men have not suc- 
 ceeded in founding a desirable state of civilization in the 
 country, but there are various reasons for this. In the 
 first place the initial Portuguese stock, although in 
 the past it has produced hardy and adventurous spirits, 
 represents an admixture of many racial elements some 
 of them undesirable, and that part of it inhabiting 
 Brazil has undergone deterioration by a strong inter- 
 
MEDICAL REPORT 109 
 
 mixture of negro. ^ Where we have found native Portu- 
 guese both among the laboring and the higher class, they 
 seemed a virile people. The foreigners coming into the 
 country have not the idea of settling and using the land, 
 but of temporarily exploiting it. A rather interesting 
 experiment was made shortly after the Civil War when 
 a number of Americans from the southern states were 
 induced to settle in the country. The experiment was 
 naturally a failure; the colonists were totally ignorant of 
 the country and were from a class which had always 
 been able to live from the work of others. Some of them 
 returned, some died, and a few intermingled, as is shown 
 by an occasional name remaining. The captain of an 
 English steamer expressed his surprise to me at finding 
 some Portuguese on the river named Jennings. Even 
 the English in the tropics have not been a working 
 people, but have lived from the work of others, though 
 they have often directed the work of the natives in 
 directions to their advantage. Under this white control 
 in the English colonies the natives have had just treat- 
 ment and have attained a greater degree of well-being 
 than without it. 
 
 In this country there can be no possibility of the de- 
 velopment of such a civilization as in India for instance. 
 There is no population to furnish labor. The Indians 
 are few and seem to be rapidly diminishing. It is doubtful 
 
 ^ The history of the relation between the Portuguese and the Indian 
 population does not form pleasant reading. From the first their efforts 
 have been directed to the enslavement of the Indians and the forced utiliza- 
 tion of their labor. This was interfered with by the missionaries and led to 
 the expulsion of the religious orders, which was most unfortunate. The 
 Spanish civilization entering from the west was not so sordid for it was 
 primarily directed toward the Christianizing of the natives, and in the pro- 
 cess their well-being was not neglected. The missionary work of the Jesuit 
 and Franciscan orders in South America forms a bright page in the history 
 of the church. 
 
110 THE RICE EXPEDITION TO BRAZIL 
 
 if even under just treatment they would be efficient 
 in labor, although the experiment has not been tried. 
 Where a minimum of work produces sustenance it is 
 difficult to procure labor even for the rewards which 
 civilization offers the savage, such as the rum, sewing 
 machines, music boxes, and patent medicines already 
 referred to. The importation of Asiatics has been 
 thought of by the government as a possible source of 
 labor, but it is doubtful if they could be induced to come 
 for terms of years and the people fear the unrestricted 
 competition of a vigorous race. Whatever the future 
 development of the country, it seems to us that it must 
 be by a people who themselves will work and who will 
 slowly evolve a civilization adapted to the environment 
 and which may be a high type. 
 
 But what is most needed in the country at present is 
 accurate information about everything. For one thing 
 the establishment of plantations for the experimental 
 study of the agricultural possibilities similar to the ex- 
 perimental farms which in all civilized lands have 
 proved to be of great service. Forestry stations where 
 the forest could be intensively studied and the possibil- 
 ities of its utilization determined would be of equal value. 
 There are already at hand admirable opportunities for 
 the study of the diseases of the country in such cities as 
 Para, where there is a well equipped, well conducted 
 hospital, but owing to lack of properly trained men its 
 superb opportunities for study are not availed of. It 
 would be of great advantage to have some of our trained 
 medical students serve an internship in this hospital 
 and receive the stimulation which the study of new con- 
 ditions brings. Throughout the most interesting parts 
 of the region suitable opportunities for study do not 
 exist and it would be important to establish a small 
 
MEDICAL REPORT 111 
 
 hospital and clinic at San Isabel on the Rio Negro, for 
 the intensive study of the diseases of this region. Little 
 can be effected by mere expeditions into the country, 
 with superficial study of conditions, although by con- 
 centration on single problems something might be 
 gained. The physical features of a country can be 
 studied in that way and accurate information of great 
 value obtained as is shown by Chandless' study of the 
 Purus River and Rice's study of the Uaupes. The 
 Agassiz expedition also should have given much knowl- 
 edge of the fishes of the region but the material obtained 
 was never described. There seems in the hurry of 
 modern life and the intense differentiation of pursuits 
 no room for the man who was formerly known as the 
 naturalist, the last of whom seems to have been Fabre. 
 We owe most knowledge of the country to such men in 
 the past, who, living here for a long time, have studied 
 life in its environmental relations and have given the 
 world in fascinating description the knowledge they 
 acquired. We allude particularly to Spix and Martins, 
 Bates, Spruce, Wallace, Smith, and Belt, although the 
 latter worked in another field but one in which much 
 the same conditions prevailed. All of these men had the 
 general knowledge which enabled them to study bio- 
 logical phenomena in their mutual relations, and this 
 in no way interfered with their intensive study of partic- 
 ular problems. It is just this long continued study 
 which is necessary for acquiring the knowledge of the 
 phenomena of disease in the country, and which will 
 lead to the solution of some of its problems. It is a 
 fascinating field for human endeavor and should at- 
 tract to it men who are desirous of a service which 
 has the double advantage of benefiting mankind and 
 giving the worker joy in his work. Life in the country 
 
112 THE RICE EXPEDITION TO BRAZIL 
 
 is easy, it is inexpensive, the people so far as we have 
 seen them are kindly, and hospitality is shown in all 
 directions. It would hardly be too much to say that a 
 decent man provided with a hammock to sleep in and a 
 few changes of clothing could live and work in the coun- 
 try at a minimum of expense. Medical men would have 
 a great advantage over other investigators in that their 
 medical knowledge could be availed of, but they must 
 know how to pull teeth. There is one thing to be borne in 
 mind ; the Amazonas is a country of one language ; that 
 language is Portuguese, and its attainment is not easy. 
 The only interpreters available are the Barbados 
 negroes, their capacity is limited, and facility in the 
 language is a sine qua non. 
 
 The land is a fascinating one. The sky, the forest, the 
 rivers, have a beauty all of their own and unmatched. 
 The great billows of white and purple cumulus clouds 
 rolling to the west, mounting to the zenith, changing, 
 disappearing, and forming, sunsets when sky, air, and 
 water all glow with rosy light, the still nights with bril- 
 liant stars in the black sky, the dawnless day when the 
 sun bounds into the sky, the marvellous beauty of tree 
 life, particularly the palms, the great forest, beautiful, 
 mysterious, fear inspiring, unchanged and unchanging, 
 the exuberance of life, all these when once felt will never 
 be forgotten. 
 
MEDICAL REPORT 
 
 113 
 
 Barbados 
 
 We arrived in Barbados November 23, and spent two 
 days on the island. It is a small (166.3 square miles) 
 very fertile island of coral formation, the principal city 
 and harbor at Bridgetown on the west side. At the time 
 
 ] 
 
 
 
 w 
 
 4 
 
 k^^^i 
 
 if 1 
 
 r=* 
 
 m 
 
 
 Fig. 35. 
 
 Bridgetown: Avenue of 
 royal palms. 
 
 we were there the island was very green and beautiful 
 with great fields of sugar cane which was not yet being 
 harvested. There are excellent hotels on the ocean and 
 the climate though warm is not uncomfortable. Bridge- 
 town is one of the most attractive tropical cities we have 
 seen, the streets are clean, well shaded and most of the 
 better class of houses have pleasant gardens with fine 
 
114 THE RICE EXPEDITION TO BRAZIL 
 
 flowers, the most prominent of these being the scarlet 
 hibiscus, and blooming vines covered walls and arbors. 
 The main shade trees are banyans, mahogany trees and 
 mangoes, and there is one avenue lined with superb 
 royal palms (Fig. 35). There is a small and on the out- 
 side attractive looking hospital which we did not have 
 time to visit. The main industry of the island is sugar, 
 and at the present time this is very profitable. 
 
 The most striking feature of the island is the number 
 of negroes. They literally swarm in the town, the water 
 side is lined with them, they appear in great numbers 
 around the yacht in rude boats made of planks nailed 
 together and find both profit and pleasure in diving for 
 coins, showing great skill in this. As seen they are a 
 ragged, rather jollj^-looking lot and their nutrition is 
 good. Fish are abundant and good, and with fruit of 
 many sorts, and yams and sweet potatoes and beans, 
 form the staple food. Notwithstanding the number of 
 negroes on the island there is a large emigration, and in 
 Brazil we met them everywhere, and they often gave 
 good service as interpreters. 
 
 The highest population seems to have been reached in 
 1891 when it was 182,306. In 1911 the population was 
 171,983, formed by whites 12,063, mixed 41,533, and 
 118,387 colored. The birth rate is high, 40 per 1000, 
 the death rate low, and the population is kept within 
 reasonable bounds (in 1911 it was 1034 per square mile) 
 by emigration. BetAveen 1861 and 1871, 31,787 left the 
 island and this rate of about 3000 per year has kept up; 
 20,507 went to the Panama Canal alone. Of course 
 emigration takes away the best part of a population and 
 it is remarkable that the present population should give 
 no evidence of decline in vigor. The very excellent 
 police force on the island is negro with white ofiicers. 
 
MEDICAL REPORT 115 
 
 The relation with the whites is good, there are sufficient 
 schools and as we have seen these Barbados negroes in 
 Brazil and in the United States, they appear far more 
 industrious and intelligent than do the negroes of the 
 southern states. 
 
 The island must be regarded as one of the most 
 healthy of places in the tropics, so far as we have means 
 of judging. Law (" Malarial and Filarial Diseases in 
 Barbados," Jour, of Tropical Medicine, 1901) found 
 no malaria and no anopheles mosquitoes. Careful 
 examination of the water of the two swamps on the 
 island showed no anopheles larvae which substantiates 
 the claims of Barbados medical authorities that all 
 cases of malaria are imported. Filariasis on the con- 
 trary is common; 12.66 per cent of 600 people examined 
 showed the parasites and the culex fatigans, one of the 
 carriers of the disease, is numerous. A rather large 
 percentage of the positive cases of filaria, 35 per cent, 
 showed pathological conditions, elephantiasis, chyluria, 
 lymphangeitis, depending upon this. Daniels also 
 states that among the large numbers of Barbados 
 negroes who annually emigrate to British Guiana he 
 found no large spleens or evidences of chronic malaria. 
 
 Porto Rico 
 
 On our return we reached Porto Rico on April 15 and 
 spent three days on the island. The harbor of San Juan 
 is spacious and almost landlocked, being inside of a long 
 projecting point on the north side of the island. The 
 town has nothing of the aspects of a tropical town, and 
 is lacking in picturesqueness. The houses generally of 
 two or three stories, are in contact, there are no gardens 
 about them, no vines clambering over walls. The 
 streets generally clean, are narrow, as are the sidewalks. 
 
116 THE RICE EXPEDITION TO BRAZIL 
 
 There are few trees in the city, the pubHc squares are 
 few and not in good condition, and there is no park 
 worthy of the name. The town gives the impression of 
 prosperity. The idle negroes on the water front, usually 
 a familiar sight in the tropical American cities, are lack- 
 ing, and there are few only who pick up a precarious 
 livelihood as watermen. There are few cafes and 
 drinking houses and few idlers. 
 
 The suburbs, which have undergone a considerable 
 extension since the American occupation, cover a much 
 greater area than the city itself, extending for miles into 
 the country. Most of the houses are new, a few of them 
 attractive looking, and have small gardens around them. 
 It is singular that in building advantage should not have 
 been taken of what the experience of ages has shown to 
 be the most suitable for the tropics. A low house with 
 walls of some heat-resisting material, an inner shaded 
 court, large rooms with comparatively small windows 
 so that both light and heat can be excluded, and floors 
 of tile, brick, or clay. The color is also important and 
 should not strongly reflect the sun's rays and should har- 
 monize well with an environment in which the verdure 
 of growing things predominates ; a soft pink seems best 
 to meet this requirement. The majority of these new 
 suburban houses are just such as we might see in an 
 American suburb. There are several conveniently 
 placed and well operated tramway lines, and excellent 
 and relatively cheap automobile lines running between 
 all of the principal cities. 
 
 Ponce, on the south side of the island, connected with 
 San Juan by a wonderful automobile road, is much more 
 attractive. There are a number of handsome squares 
 with well cared for trees and shrubs and the streets are 
 shaded with fine mango trees. The houses are separated 
 
MEDICAL REPORT 117 
 
 and there are gardens about them. It would seem to 
 have been more of a residence city than San Juan and 
 to have had well-to-do residents. 
 
 The island is mountainous. There is an irregular 
 chain of mountains in the centre with summits up to 
 forty-six hundred feet high with lower mountains which 
 extend chiefly on the north side. On the south side the 
 slope to the sea is more regular. The interior is much 
 broken up, there are numerous valleys, never broad but 
 narrow, some of them rather ravines than valleys. Nor 
 are there any broad plateaus on the summits, but the 
 whole landscape is broken up with ridges and sharp 
 peaks. The soil appears to be very light but good, and 
 is cultivated on mountain-sides so steep that horse labor 
 would be impossible. 
 
 The rainfall is abundant, but with marked local varia- 
 tions and greater on the north than on the south side of 
 the island. The soil, notwithstanding its lightness, 
 seems to possess some peculiar quality which prevents 
 it from washing. Numerous streams come down from 
 the mountains and the water is extensively used for irri- 
 gation on the sugar plantations on the south side of the 
 island, this being assisted by the construction of reser- 
 voirs in which the water is impounded. There is inten- 
 sive cultivation of the land in the western two-thirds of 
 the island, the main crops being tobacco, sugar, and 
 coffee. Most of the tobacco is grown in the narrow val- 
 leys in the interior of the island, and on the steep moun- 
 tain sides. In places there are large areas of tobacco 
 grown under cheese cloth. There are great plantations 
 of sugar, generally owned by companies, and the culti- 
 vation is on a large scale. Coffee, and there is no better 
 coffee, is grown on the summits of the mountains in the 
 interior. The coffee plantations received great injury 
 
118 THE RICE EXPEDITION TO BRAZIL 
 
 from a hurricane in 1898 and have never recovered from 
 the damage, as both the coffee shrubs and the trees 
 which protect them were destroyed. A railroad, with 
 infrequent passenger service, extends around the island, 
 with branches running inland and from this there are 
 spurs and often temporary tracks extending into the 
 sugar estates. A great deal of the cane is hauled to the 
 mills on these roads, but the bulk of it is hauled on carts 
 drawn by single or several yokes of splendid oxen. The 
 mills are large and placed at intervals. The population 
 is large and concentrated at more highly cultivated 
 regions. There are comparatively few negroes and the 
 admixture with negro blood is not so manifest as in 
 Brazil. There is a great concentration of people in vil- 
 lages and small towns, particularly on the southern side 
 of the island, where the sugar estates are situated. The 
 people of wealth seem to live in the cities, at least no 
 large residences were seen in the country. The people, 
 as they are seen along the roads, and elsewhere, partic- 
 ularly among the mountains, do not give the impres- 
 sion of good health and nutrition. They are rather pale, 
 spare, and seem devoid of vigor. There is a singular 
 difference as compared with the peasant class in Brazil. 
 Shoes are very generally worn, although we did see an 
 occasional barefoot laborer. 
 
 We had the opportunity of seeing the pupils in a large 
 public school of the middle grade in San Juan, and here 
 the children in point of health and nutrition seemed to 
 be in a fair state. A primary school was also seen in one 
 of the interior towns, and here also the much younger 
 children looked pretty well. Shoes and stockings were 
 generally worn by the school children. The general use 
 of foot covering was probably a result of the vigorous 
 
MEDICAL REPORT 119 
 
 hookworm campaign which began with the remarkable 
 work of Ashford and King in 1902. 
 
 The general conditions of life of the peon, or laboring 
 population, on whom the prosperity of the island imme- 
 diately depends, seem to us deplorable. It is probably 
 due to the fact that they own nothing of the island. 
 Their dwellings are the most wretched shacks, worse 
 than any human habitations we have seen. When 
 situated in the fields the land is cultivated right up to 
 the houses, giving no possibility for the domestic garden. 
 These shacks are usually along the roads, and in the 
 vicinity of the towns on the southern side there are col- 
 lections of box-like houses so tiny that it did not seem 
 possible that human beings could live in them, closely 
 clustered, with no cultivated land belonging to them. 
 Fruit is one of the necessities of the tropics and it forms 
 in its many varieties of bananas, mangoes, oranges, bread- 
 fruit, etc., probably the most valuable and cheapest 
 form of food. In the rapidity with which growth takes 
 place it is possible on an area of one hundred and fifty 
 feet square for an average family of five to raise all or 
 nearly all the fruit and vegetables, the most important 
 of the latter being yams and beans, that it requires. In 
 no place we have ever seen, save in the heart of a great 
 city, is there such a complete deprivation of the toiler 
 from the use of the earth as here. The wretched peon 
 must buy everything and the very insufficient wage 
 gives him only the poorest food in insufficient quantity. 
 Meat he never tastes and the diet is practically confined 
 to salt fish and rice. With the garden it would be pos- 
 sible, even without some use of the surrounding crops 
 belonging to the soulless corporation, though this might 
 be considered legitimate, for the laborer to raise a few 
 
120 THE RICE EXPEDITION TO BRAZIL 
 
 pigs and chickens which would give him the requisite 
 animal food. It is interesting in this respect to recall 
 conversations which we had in Brazil with other than 
 the laboring class, in which the misfortune of the 
 country in the lack of an active and efficient labor-, 
 ing class was attributed to the easy culture of the 
 bananas and the abundance of fish in the rivers. 
 For, said they, no man will work if he can without 
 trouble build a house anywhere in a few hours, pluck 
 bananas at his doorway and in a half -hour of the pleas- 
 ant diversion of fishing secure the riieat for a couple of 
 days. While there is no doubt that a greater necessity 
 for struggle of maintenance will produce qualities excel- 
 lent for a race, there is equally no doubt that such with- 
 drawal of the use of the land from the people leads 
 practically to a condition of slavery where people must 
 work, and in prescribed ways, in order to live. We have 
 spoken of this matter, having in view not so much the 
 social aspects as the medical aspects. Medicine aims 
 primarily at the freeing of a people from the chains that 
 disease lays upon them, disease not only giving pain and 
 .suffering, but preventing the legitimate enjoyment of 
 the fruits of life. The strictly medical work which has 
 been accomplished in Porto Rico by the campaign 
 against the menace of the hookworm, the provision of 
 laboratories and hospitals, has been most excellent and 
 beneficent, but restoration of the use of the earth to the 
 people in some measure would be of greater value. No 
 permanent reform, either social or medical, will be 
 possible without it. 
 
 There is an interesting relation between the agricul- 
 tural conditions on the island and diseases. Following 
 the American occupation there was a careful survey of 
 health conditions and as a result of the extensive and 
 
MEDICAL REPORT 121 
 
 serious conditions which were shown to be produced Ijy 
 hookworm infestation an energetic campaign against 
 this was instituted in 1902 and splendidly directed by 
 Ashford and King. Dispensaries were established for 
 treatment in the cities and in the towns throughout the 
 most populous part of the island, and the treatment was 
 effective, as shown by a re-survey and determination of 
 hemoglobin. It seems to us, however, doubtful whether 
 there can be a thorough extirpation of the hookworm in 
 a region where infestation is so general. The most 
 effective measures are educational and social, rather 
 than medicinal. That the people are aware of the na- 
 ture and importance of some of these preventive meas- 
 ures is shown by the general adoption of foot covering. 
 The most important preventive measure, the provision 
 of privies and the prevention of soil pollution with the 
 faeces containing eggs, has made no headway. It is 
 doubtful if there is a single privy in the rural districts of 
 the island, certainly none were seen. The hookworm 
 campaign, however, hardly affected the mountain dis- 
 tricts, where coffee is the main crop and where the 
 population is sparse. Coffee culture has not been pro- 
 fitable, the plantations were destroyed in 1898 and the 
 coffee, although of excellent quality, is not generally 
 highly esteemed by us and formerly was consumed in 
 Europe exclusively. The coffee of Vienna, which all 
 who have been there will remember with pleasure, was 
 produced in Porto Rico. In this coffee region the road 
 system which is so admirable elsewhere, hardl}' pene- 
 trates, the villages are inaccessible and the bodily 
 strength and intelligence of the people below the aver- 
 age which obtains elsewhere. The best of the population 
 go into the sugar and tobacco regions where the con- 
 ditions of life are more favorable and the remaining 
 
122 THE RICE EXPEDITION TO BRAZIL 
 
 population ekes out a miserable existence. Payment 
 for work on the plantations depends upon the amount 
 of labor given and is by piece, and a vicious circle results 
 in that the greater the weakness produced by the disease 
 the less work can be accomplished, the wage is reduced 
 and poverty and ignorance are the most important 
 accelerators of the hookworm morbidity. In the coffee 
 region there is universal soil pollution, combined with 
 dampness and shade, which prevents the drying-up of 
 the faeces; and the beneficent though in some respects 
 disagreeable scavenger, the ant, does not play the 
 important role which it does in Brazil. Poverty prevents 
 in this region the general use of foot covering which is a 
 very important means of prevention. Physicians are 
 few in the rural districts and the poverty of the people 
 would not enable them to receive the proper recompense 
 for medical work. Under such conditions practically 
 the entire medical care is taken over by the drug stores 
 in the villages, to which the people resort, and under 
 these conditions the patent medicine evil flourishes. It 
 is a pity that the dispensaries which were instituted 
 during the hookworm campaign were given up from 
 lack of means. Instead of that they should have been 
 extended and combined with a system of small hospitals. 
 More important than roads or even schools is the health 
 of the people. Schools, of course, play an important 
 role and there cannot be much advance unless the means 
 of communication with the past as well as the present 
 be possessed, but the part which the school plays in 
 increasing the power, the well-being and happiness of a 
 people is grossly overestimated. Money had much 
 better be used in promoting the health of a people than 
 in an extension of what may in great part be regarded 
 as useless work. A hospital, in addition to the imme- 
 
MEDICAL REPORT 123 
 
 diate good which it accompHshes in the reUef or cure of 
 disease, is an educational factor of great value. And the 
 knowledge of proper living and of the means for care and 
 prevention of disease which the people acquire while 
 living in the hospital is a part of education, and as an 
 agent for the extension of morality the hospital is of as 
 great value as a church. 
 
 Malaria, of course, exists, but it does not seem to play 
 as great a role in the country as it does in parts of the 
 Amazons. In San Juan we visited the small but excel- 
 lently administered public hospital. It presented the 
 evidence of what excellent work can be accomplished 
 with means seemingly inadequate but used with intel- 
 ligence and directed by scientific enthusiasm. The 
 hospital is an old building, small and inadequate. It 
 did not, for instance, compare in material aspects with 
 the hospital in Para, but one had only to enter the wards 
 to see that a totally different spirit prevailed. The 
 manifest difference was accuracy of diagnosis, knowl- 
 edge of the condition of the patients, based on scientific 
 study, and with this a far greater interest in the patients. 
 This seemed to be due to the presence in the hospital 
 of a trained pathologist with a laboratory pretty well 
 equipped for simple work, and who possessed energy 
 and scientific interest. One thing we were told there 
 which was interesting, was the relation between child- 
 birth and malaria. In patients with chronic malaria, 
 but who showed no symptoms whatever of the disease, 
 childbirth was frequently followed by an acute exacer- 
 bation of the disease. This was probably to be attri- 
 buted to the increased intra-abdominal tension of 
 labor, forcing into the circulation organisms Avhich were 
 quiescent in the spleen. By work in the hospital the 
 great frequency of filaria in the island was determined. 
 
124 THE RICE EXPEDITION TO BRAZIL 
 
 This, however, seems to produce no symptoms. We 
 were informed by the very capable administrator of the 
 hospital that, owing to the increased cost of living, his 
 salary had been reduced. 
 
 We also had the pleasure of visiting the government 
 laboratory, which is under the direction of Major Ash- 
 ford. It is a well provided and administered institution 
 and was organized shortly after the American posses- 
 sion. The laboratory was the efficient instrument in 
 the suppression of yellow fever on the island, the centre 
 from which the hookworm work extended, and from it 
 have come some notable contributions to knowledge of 
 disease. The most recent of these has been the work 
 showing the etiology of sprue, which is one of the serious 
 tropical diseases. What a change is represented in the 
 general point of view when almost the first thing which 
 a government does when it becomes possessed of a new 
 land is to establish a laboratory for the investigation of 
 disease ! On the medical care of the people and the pre- 
 vention of disease the happiness and well-being of the 
 people, and the success of the administration primarily 
 depend. 
 
 The schools on the island, each proudly displaying an 
 American flag, are numerous, and those we visited were 
 well attended and administered. Of those in the coun- 
 try districts we could not judge. We were informed, 
 however, by the principal of one of the high schools that 
 the accommodations were inadequate and that two hun- 
 dred and fifty thousand children on the island were 
 without schools, but this is probably an exaggeration. 
 
 It is impossible to leave this very interesting island 
 without offering, but in a spirit of modesty, certain sug- 
 gestions. All suggestions of course should be made with 
 a full knowledge of environmental conditions, and these 
 
MEDICAL REPORT 125 
 
 cannot be ascertained in a visit of three days only. Cer- 
 tain things seem to be apparent, but whether the sug- 
 gestions could be put in force and whether if so they 
 would be beneficial must be left to the judgment of 
 others. The first would be in regard to the relations of 
 the laboring class to the land. The people should live 
 on the land where they find employment and each house 
 should be provided with land on which the settler could 
 raise an important part of his food. Provision should be 
 made by the government for the people to acquire pos- 
 session of a home on easy terms. The collections of dog 
 houses about some of the towns, in which the people 
 live, should be destroyed. It is such conditions in which 
 the people have no stake in the land, nothing to lose, 
 and possibly something to gain, by a change, which 
 make revolutions possible and true progress impossible. 
 We believe that this is in all respects the most important 
 social and medical reform which can be instituted. The 
 second suggestion is the reestablishment and the con- 
 tinuance of the medical foci for the relief of hookworm 
 disease and other conditions. The wealth of the island 
 primarily depends upon the efficiency of the labor used 
 in the cultivation of the soil, and a laborer in whom 
 hemoglobin is deficient can never be efficient. 
 
 Such a small island as this presents an interesting 
 problem in government. There is sufficient diversity 
 of interest to present problems of public economy, and 
 conditions, both of population and region vary suf- 
 ficiently to produce many problems of public health. 
 The environment is small and the interrelations are not 
 so complex as to render the problems insoluble. More- 
 over, mistakes both in political and health management 
 are not so productive of harm as in more complex rela- 
 tions, the results are more quickly manifest and changes 
 
126 THE RICE EXPEDITION TO BRAZIL 
 
 can be more quickly made. In a certain way an island 
 can be regarded as an experimental station, where vari- 
 ous experiments in administration can easily be made 
 and would entail little cost. For instance, on such an 
 island the very interesting question as to the possibility 
 of hookworm extirpation and even the best methods of 
 permanent relief could be determined. Experiments in 
 government might also be used to determine what is the 
 end to be striven for, the general well-being and happi- 
 ness of the people as a class or the unrestricted exploita- 
 tion of both the soil and the people towards the end of 
 wealth production. Living problems of education could 
 also be tried out experimentally. It seems to have been 
 shown that a nation by means of education carefully 
 directed to one end and embracing such means of educa- 
 tion as the school, the university, the press, the pulpit, 
 and the army, can be radically changed, at least for a 
 time. It might be determined whether nobler ideals 
 than even well-being and happiness can be attained or 
 whether all effort is vain. 
 
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