^s il; ^ T^ YtO^' ^. ¥^' ^ fl 1 J ? J «>< -i ■iHKmi^jm -e '^ 75. Importance of Cost Element. 76. How "Per Capita Cost" is Figured, 'j'j. Cost Indices of West Indies Intensive Work. 12 CONTENTS CHAPTER PAGE XL Conclusion 103 78. Wide Applicability of Intensive Plan. 79. Educational Value of Intensive Meas- ures. 80. Intensive Method as Means of Gaining Good-will of Populace. Illustrations 111-118 APPENDICES PAGE I, Results Accomplished 121 II. Forms used in Intensive Work 123 I. Census Book. 2. Case-Record Book. 3. Microscopic Report Sheet. 4. Treat- ment Book. 5. Nurses' Reports: Daily, Weekly, Summary. 6. Diary, Educa- tional Work. 7. Geographical Area Re- port on Completed Work. 8. Quarterly Report on Completed Work. 9. Quarterly Report on Work in Progress. 10. Special Monthly Report for the Information of Regional Directors. 11. Narrative Re- port. 12. Budget. 13. Quarterly and Yearly Financial Reports. III. List of Standardized Supplies and Prices. 165 IV. Dosage Table 168 V. General Instructions for Nurses 169 VI. Contract with Subordinate Employes... 172 VII. Sample Circular Used in British Guiana. 174 VIII. Description of Special Centrifuge 176 I PROBLEM OF HOOKWORM CONTROL 1. Magnitude of the Problem. Hookworm disease is found in practically all countries which lie in the tropical and sub-tropical zones, extending from parallel 36 degrees north to parallel 30 degrees south. More than half the population of the globe lives in this area. The control of this disease is therefore an under- taking of enormous magnitude, which can be accomplished only by permanent agencies work- ing over a long period of time. 2. Theoretical Simplicity of Control Meas- ures. There is probably no other disease, cer- tainly no other parasitic disease, of which our knowledge is so complete as of hookworm dis- ease, and for which we have two or more specific drugs. There is not a stage in the life-cycle of the hookworm with which we are not thor- oughly familiar, from the moment the egg reaches the soil in the feces of its former host and hatches into the larva, throughout all the stages of development, until, in its encysted stage, it enters the human body and finally reaches the small intestine, there to live for eight or ten years and to reproduce its kind 13 14 INTERNATIONAL HEALTH BOARD by countless thousands. Every detail of its life-story and of the environment necessary for its development has been made completely known to us by the researches of scientists. With such thorough knowledge it has been an easy task to elaborate a perfect theory for the prevention of the disease. Only one thing is necessary: that is, to prevent soil pollution, or, in other words, to keep the hookworm ova from reaching the soil, where they can hatch and develop into infective larvae. If those who have hookworm disease can be located and cured, and if we can prevent others from con- tracting the disease, then, theoretically, com- plete eradication is an accomplished fact. 3 . Practical Difficulties Experienced in Carry- ing out Control Measures. Although the prob- lem of complete eradication seems simple on paper, it is not so in fact. Many difficulties arise to prevent working it out to the end. Virtually every difficulty, however, may be rightly attributed to one cause: lack of proper co-operation on the part of the people who are to be most benefited. This is strangely true of every undertaking, however benevo- lent in nature, where voluntary co-operation on the part of the masses is a factor for suc- cess. To accomplish the complete eradication of hookworm disease in any area we need PROBLEM OF HOOKWORM CONTROL 1 5 only to make a microscopic examination of every one living therein, to treat every one found infected until he is cured, and to bring about the installation and use of sanitary con- veniences that will put an end to further pollution of the soil. But there are obstacles in the way of each of these apparently easy steps. a. The examination of every individual in a given area will rarely, if ever, be possible. There will always be those, few or many as the case may be, who will refuse to submit specimens. A false sense of modesty will de- ter some; others, because of social promi- • nence, wealth, or intellectual attainment, will take it for granted that they are immune to the disease. Mildly infected persons, feeling in good health and believing they have no need of treatment, will not be convinced that, as carriers, they are dangerous to their communi- ties. A few will be openly hostile, fancying that they see in the campaign an attempt to interfere with their personal liberties; while the full co-operation of others will sometimes be withheld through ignorance, superstition, in- difference, or neglect. b. Cure depends upon the willingness of the patients to take treatments for a sufficient length of time. As in the case of examination. l6 INTERNATIONAL HEALTH BOARD and for the same reason, there are some who are unwilling to be treated, even though they have been examined and found infected with the parasites. There are others who lose pa- tience and abandon treatment short of cure, and a small number who must be refused treatment because they are suffering from other diseases or conditions which prohibit the use of an anthelmintic. Usually the number refusing or abandoning treatment is smaller than that re- fusing examination in the first instance. c. The failure of the people to give perfect co-operation in these first two phases of a cam- paign must result in the main from misinforma- tion and misunderstanding; it is chiefly here that the patience, persistence, and tact of the medical director and of the nurses come into play. d. The installation and use of proper sani- tary conveniences to prevent further soil pollu- tion it is possible to bring about. This has been proved in some of the West Indian colo- nies. Compulsory laws with penalties, if en- forced, will secure results; but better and much more to be desired are the results ob- tained by the education and enlightenment of the public to the point where eventually it will demand such improvements. After sanitary conveniences are installed, we still face the PROBLEM OF HOOKWORM CONTROL I J difficulty of holding the people to the use of them. This has not, however, proved in our experience the hopeless task that some have thought it to be. In the West Indies, with their mixed population, the patient, tactful, and yet firm handling of this question has brought really remarkable results. e. If it were possible to accomplish per- fectly the above purposes of the campaign, there would still remain for a time the danger of re-infection from hookworm larvae already in the soil, which we know live, under favor- able conditions, for some months. Because of the labor involved, it is often impracticable to attempt to locate areas where the soil is in- fected with hookworm ova and larvae; and if such areas were located they would probably be too extensive to justify attempts to render them innocuous or to keep people away from them. Attempts at the destruction of hookworm ova and larvae in the soil by the use of chemi- cals have not been very successful. In a paper read befoi'e the Society of Tropical Medicine and Hygiene by Sir Thomas Oliver in 1910, the statement is made that: "The one salt which has given the most satisfactory results all around is iron sulphate. It is estimated that one ton of this in a one-per cent solution 1 8 INTERNATIONAL HEALTH BOARD would cover a length of sixty miles more than a yard wide and one-third of an inch deep." This solution was used to a limited extent in the first organized effort against the disease in British Guiana, but it was most difficult really to prove its efficiency. A more practical step was to burn brush and trash piles on spots likely to be infected, such as sites of surface closets, stooling places in thickets and in the cane-fields, and vegetable patches. It would be possible, of course, to meet these particular difficulties by keeping the entire pop- ulation under observation until sufficient time had elapsed for all hookworm larvae in the soil to die — probably about ten months; or by returning to the area to find and cure the cases resulting from such re-infection. 4. Responsibility of Local Agencies. The International Health Board does not undertake on its own account to relieve and control hook- worm disease in any country. If the work is to be successful, the state or country in which the infection exists must assume the burden and responsibility. The Board has had the privilege of sharing in the work in various countries, however, by making contributions toward its support and by lending a few well- trained men to aid in its organization. This co-operative effort is intended in most instances PROBLEM OF HOOKWORM CONTROL I9 to serve as a demonstration, which, by proving the feasibiHty of attaining the end in view at a non-prohibitive cost, will lead to the establish- ment of permanent agencies to extend the work to wider fields. In its co-operative efforts with the different states and countries, the Board leaves the pre- ventive side of the problem — that of securing the installation or improvement of latrines followed by the continued maintenance and use of them as a safeguard against infection and re-infection — entirely in the hands of the local governments. Though its field forces devote a certain proportion of their time to educating the people in sanitation, this is but an incident of the Board's work, its immedi- ate object being the examination of the people and the treatment and cure of those infected. II INTENSIVE METHOD OF ATTACKING THE DISEASE 5. Definition of the Intensive Method. The intensive method may be briefly defined as an attempt "to approximate, as nearly as prac- ticable, the complete relief and control of hook- worm disease within a given area." ^ The plan of operation comprises two undertakings, each with its own agency. The first of these under- takings, for the maintenance of which the International Health Board contributes funds, endeavors to treat until cured all infected per- sons dwelling within the area; the second, financed by the government and operated by its sanitary organization, aims to make effec- tive such measures as will prevent re-infection. The scheme for treating the infected requires: mapping the territory, locating roads, streams, villages, houses; taking a census of the popu- lation, numbering the houses in which the people live, recording name, age, sex, race, and post-office address; making microscopic examination of the entire population; putting under treatment all persons found infected; and continuing treatment of each patient until microscopic examination following a standard- ^ First Annual Report, International Health Board, p. 28. 20 METHOD OF ATTACKING THE DISEASE 21 ized procedure shows that a cure has been effected. While this work Is being carried on, a sys- tematic effort Is made by means of pubHc lec- tures, the distribution of literature, newspaper articles, and house-to-house visits, to educate the people, not alone with regard to the cure and prevention of hookworm disease, but also as to the dangers of soil pollution and Its close relationship, as a causative factor, to many other diseases. This method of conducting Intensive opera- tions In well defined areas has advantages that are worthy of special note: namely, the work Is definite and thorough and closely approxi- mates completeness; and where the sanitary work keeps pace with the work of treatment and cure, the results are lasting. By this means the government is enabled to begin a definite sanitary work on the basis of an almost insignificant expenditure, and to train and enlarge its sanitary force gradually as the work is extended from area to area, and as the people are educated to the point of giving greater co-operation. 6. Development of the Intensive Method. It was in British Guiana on March 12, 1914, that work by the Intensive method was under- taken by a foreign country In co-operation 22 INTERNATIONAL HEALTH BOARD with the International Health Board for the first time. Following the visit to this colony in October, 191 3, of the Board's General Di- rector, a working plan and budget, prepared by the Surgeon General with the assistance of Dr. J. E. A. Ferguson, Medical Officer of Peter's Hall district, were submitted to the Board. This plan and budget were adopted, and it was decided to select a medical district as the area of operation in the preliminary campaign. The Peter's Hall district, just south of the city of Georgetown, was chosen. This district is approximately eight miles long and from one to three miles wide, with a population of 14,000 people, exclusive of the indentured labor on the sugar plantations. It contains few isolated dwellings. The people live in a chain of villages, varying in size from 200 to 4,000 inhabitants, lying along the east bank of the Demerara river. The indentured plantation laborers were not to be dealt with, as they were already being handled effectively by Dr. Ferguson at the expense of the plantation owners. The writer, who, as a member of the medical staff of the International Health Board, had been selected to co-operate with the Colonial government in carrying on the work, arrived in Georgetown on March 9, 1914. It became METHOD OF ATTACKING THE DISEASE 23 at once evident that there were features of the problem in British Guiana which neither the work conducted against hookworm disease in the United States by the Rockefeller Sani- tary Commission, nor the local efforts in the colony to control it among the indentured laborers on the plantations, had encountered. In the United States the sanitary conditions are not made worse by heavy tropical rains. Moreover, the temperature in the winter months not only compels the people to wear shoes, thus protecting themselves from infection as well as from cold, but also kills off hookworm larvae in the soil. In British Guiana the temperature is always warm. The people go barefoot the year round, and at certain seasons there are heavy rains almost daily. In the United States the population that had been handled was made up of blacks and whites only, and was intelligent enough to be amenable to reason. In British Guiana the indentured labor that had been and was being handled was made up almost entirely of East Indians subject to estate discipline. But in the Peter's Hall district, on the other hand, the population was very heterogeneous and diffi- cult to influence. There were East Indians who had served out their indenture, and who, being no longer subject to discipline, were, like the 24 INTERNATIONAL HEALTH BOARD rest of the population, intolerant of it. There were numbers of Portuguese, especially sus- ceptible to the disease, severely infected, and yet stubbornly indifferent to all efforts made to cure them. There were Chinese, who are averse to taking medicine of any kind unless they are suffering acute pain; and blacks, the more ignorant of whom gave trouble all along. Only the "coloreds" could generally be de- pended upon for co-operation. The task of unifying all these diverse ele- ments of population and of creating among them an active common interest in measures for the control of a disease about which they were entirely ignorant and utterly indifferent, was no small undertaking. We have since found these general condi- tions repeated in all the other West Indian colonies where we have taken up work against hookworm disease. There are a few minor differences. In Dutch Guiana ten per cent of the population is Javanese, mainly indentured laborers; in most of the northern islands the East Indian element is lacking; and in cer- tain of the colonies the free population is found more in isolated rural homes than in strings of villages. Elsewhere than in British Guiana we have undertaken the indentured labor as well as the free population. METHOD OF ATTACKING THE DISEASE 25 In the experimental campaign in Peter's Hall district the original plan of operation underwent rapid and radical changes in the course of our contact with actual conditions: the area of operation was considerably reduced, and efforts within the smaller area were inten- sified. Satisfactory progress soon gave evi- dence of the wisdom of these changes, and subsequent experience with the method thus evolved has fully justified expectations and has led to its being adopted as the exclusive type of work for the West Indies. To inaugu- rate and conduct a campaign by this method it is desirable that a definite line of procedure should be followed, which will be described step by step in subsequent pages. Ill SELECTION OF AREA OF OPERATION 7. Size of Area. The temperament of the majority of the people in the West Indian colonies is such that their interest soon wanes, even in an effort which looks to their improve- ment and benefit. In this respect they proba- bly do not widely differ from people living in other areas in the tropics. Furthermore, a large proportion are without permanent places of abode and move about from locality to locality. These two conditions suggest the desirability of concentrating the efforts of a unit of working force on a comparatively small population, of waging a rapid and aggressive campaign, and of bringing the campaign to a close before the people lose interest or before removals and additions to the population seri- ously invalidate the original census. The size of the area will largely be deter- mined by the size of the unit of working force, but if the unit of working force described on page 37 is accepted,^ experience indicates that it is best to select an area with a popula- tion sufficient to give each nurse from one ^ One medical director in charge, two clerks, four microscopists, twelve nurses, and one or two low-salaried helpers or caretakers. 26 SELECTION OF AREA OF OPERATION 2/ hundred fifty to two hundred cases to treat. Thus, with twelve nurses in the working force, the area selected would include about 2,400 infected persons. In the West Indies, where the average rate of infection has been found to be 65 per cent, this has meant that the average area has had a population of about 3,600. Usually the campaigns are preceded by survey work, which enables an estimate to be made of the degree of infection prevailing throughout the territory to be covered. The size of the area which will supply the desired population will, of course, vary in ac- cordance with the density of population. In sparsely settled sections, owing to the distances to be covered by the nurses in visiting their patients, the selection of a smaller population than that named may be advantageous, while in densely populated sections or in villages a larger population may be handled. 8. Rate of Handling the Population. The progress made by a unit of force in handling a given population is indicated by figures com- piled in the work in Trinidad and in British Guiana. In Trinidad, in a campaign which covered the six quarters from July i, 1915, to December 31, 1916, and in which a working unit of about the standard size was engaged, the following averages per quarter were obtained : 28 INTERNATIONAL HEALTH BOARD Table I — Average Number of Persons Enumerated in Census, Examined, Found Infected, Given First Treatment, and Cured per Quarter in Trinidad, British West Indies — July i, 1915, to December 31, 1916 Census 2,754 Examined 2,615 Found Infected Ij96i Given First Treatment Ij7I2 Cured 1,283 In British Guiana during the quarter ending December 31, 1916, the following statistics were compiled: Table II — Number of Persons Enumerated in Census, Examined, Found Infected, Given First Treatment, and Cured in British Guiana during Quarter ending December 31, 1916 Census 7>796 Examined 7j47I Found Infected 4>i74 Given First Treatment 35641 Cured 2,233 There were 1,293 patients remaining under treatment at the close of this quarter, so that the campaign was likely to continue for six weeks or two months longer until they were cured. Five microscopists and twenty-one nurses were included in the working staff, but the difficulties experienced by the medical director in keeping in intimate touch with the SELECTION OF AREA OF OPERATION Zg details of the work of so large a force led to a reduction in the number of nurses and micros- copists to normal proportions. 9. Duration of Work in Area. An examina- tion of the figures given above indicates that approximately three months are required for a unit of force such as is recommended, operat- ing under average conditions, to complete work in an area which includes from 1,800 to 2,400 infected persons. ID. Division of Area into Nurses' Districts. After an area of operation has been selected, it is divided into nurses' districts, each con- taining approximately the same number of infected persons, with such variations as the density of population and the consequent dis- tances to be traveled by the nurses may indi- cate. A nurse is held responsible for every detail of the work in his district. II. Consolidation of Nurses' Districts. Near the conclusion of the period of treatment, when the total number of cases remaining uncured in several nurses' districts combined has been reduced to one hundred fifty or two hundred, these several districts are put in charge of one nurse, who continues to administer treatment until all of these cases have been cured. The nurses thus released from their old districts are transferred to others within a new area of 30 INTERNATIONAL HEALTH BOARD operation. This new area usually adjoins the old. By following such a plan of consolida- tion, the entire force, both in the field and in the oflftce, keeps working at full capacity and the per capita cost of the work is materially reduced. IV PUBLICITY AND EDUCATIONAL MEASURES 12. Education the Primary Aim of an In- tensive Campaign. Although the intensive method has been defined as an attempt to approximate the complete relief and control of hookworm disease within a given area, the whole work is essentially educational: it is teaching the people by practical demonstra- tion. Among the natives in many tropical countries, the story must be presented in direct and concrete terms. Here the medical directors rely upon word of mouth; and as they tell the story they illustrate its details by lantern slides, photographs, and objects. They use typical cases as object lessons; they point out the gross clinical symptoms, which the people soon learn to recognize; they get specimens of the patients' stools and exhibit the eggs of the parasite under the microscope; they show the parasites that have been expelled by the treat- ment administered; and by means of the microscope they exhibit the living, squirming embryos that live by teeming thousands in the soil that has been befouled by an infected person and that are ready to infect any person 31 32 INTERNATIONAL HEALTH BOARD with whose bare skin they come into contact. The recovery that follows treatment and cure tells its own story, both to the patient and to his friends and neighbors. The disease thus lends itself so readily to simple demonstration that the people — even native populations of tropical countries — easily understand its whole story. They learn to recognize hookworm dis- ease by its clinical picture; they have seen the parasite that causes it and the eggs by which infection is demonstrated; and they see how the infection is spread and how it may be prevented. As a result of this educational work, the people co-operate helpfully, in both the work of treatment and that of prevention.^ 13. Purpose of Educational Work. The publicity and educational work begins imme- diately after the area of operation has been selected, and is continuous throughout the campaign. The people within the selected area must be informed about the disease and be interested in it to such a degree that they will voluntarily submit themselves for examination, and be willing to take treatment if found in- fected. In addition, they should be taught the facts concerning the transmission of hook- worm disease from individual to individual ^ See First Annual Report, International Health Board, pages 38-39- PUBLICITY AND EDUCATIONAL MEASURES 33 through soil pollution, and the necessity of each household providing itself with a latrine of proper type, so that the use of this latrine by every member of the household may stop the further spread of the disease. In educating the people on these points, a favorable oppor- tunity is afforded for valuable lessons on the prevention of disease in general. This oppor- tunity is not overlooked: every possible influ- ence is brought to bear; and while the means used vary somewhat with locality and coun- try, certain lines of effort, mentioned below, are common to all. 14. Lectures. On the opening of activities in a new area, it has been the practice to arrange for the delivery, at some convenient gathering place, of an evening lecture illustrated with stereopticon slides. To this lecture the govern- ment officials are especially invited, and par- ticular effort is made to have present as many of them as possible. Village officials, clergymen, schoolmasters, heads of societies, health officers, members of mission boards and of clubs, local representatives of the press, and officials of planters' or agricultural organizations, are also urged to attend. In addition an invitation to the general public is widely circulated. The lecture is delivered by the medical di- rector — if need be with the aid of an inter- 34 INTERNATIONAL HEALTH BOARD preter — and includes not only a discussion of hookworm disease, but an explanation of the origin of the activities to be undertaken against it, the purpose of these activities, the sources of the funds to be expended in the work, the necessity for the co-operation of the people, the benefits to be derived from such co-operation, • — individually and collectively, — and the im- portance of sanitation under government super- vision. Expressions from prominent men in the audience are cordially invited. If possible, arrangements are made for a representative of the government to preside at this meeting. Every effort at this and at all subsequent stages is made to identify the work with the central and local government agencies. As the work in the area proceeds, other less formal lectures are delivered to schools and societies, or wherever a sufficient number of people can be gathered together. 15. Distribution of Literature. The distri- bution of literature dealing with hookworm disease, its detection, treatment, cure, and prevention, prepared in language simple enough to be intelligible to the people, is of undoubted value and should not be neglected. Often, be- cause several different languages are spoken in the area, these pamphlets and posters have to be printed in a number of tongues. Literature PUBLICITY AND EDUCATIONAL MEASURES 35 especially prepared for use by local teachers in instructing native children concerning hook- worm disease and other prevailing diseases, as well as concerning the dangers of soil pollution, is of paramount importance. Experience has shown that the average schoolmaster is more than willing to use this literature and thus to lend his aid and influence to the work. 16. The Press. The local press gives valu- able voluntary support by publishing at inter- vals, with favorable comments, reports giving various details of the progress of the work. 17. Microscopic Demonstrations. Micro- scopic demonstrations of the presence of ova and larvae in feces are useful as a means of convincing the doubtful and of securing their co-operation. These demonstrations are held at the laboratory or in the homes of the people. The confidence and support not only of the professional class but of intelligent classes gen- erally, are gained by welcoming them to the laboratory and by inviting their attention to every detail of the work, both there and in the field. 18. Nurses as a Means of Publicity. The nurses, in their frequent calls at the homes within the area to collect specimens and to administer treatment, have many opportuni- 36 INTERNATIONAL HEALTH BOARD ties to win the confidence of the people and to conduct valuable educational work. It has been the practice of some medical directors to give the nurses a special course of instruction to fit them fully for this phase of their duties. V WORKING FORCE 19. Size of Working Staff. Experience gained in the campaigns conducted in the West Indian colonies during the past four years has shown that a working staff of the following size is, all in all, the most efficient unit for the relief and control of hookworm disease by the intensive method: one medical director in charge, two clerks, four micros- copists, twelve nurses, and one or two low- salaried helpers or caretakers. There is a definite ratio between the different elements of this unit of force. Only three of the microscopists work with microscopes; the fourth is chief microscopist, verifying and re- cording the work of the others and instructing them in their duties. Under average condi- tions it requires four nurses actively engaged in their routine work in the field to supply sufficient specimens to occupy the time of one microscopist. A force of the size suggested will reach so many people, and cover so extensive an area, that the full time of one medical di- rector will be needed to supervise it. For this reason it is considered as large a force as can be effectively managed by one director. If it 37 38 INTERNATIONAL HEALTH BOARD is desirable to handle the population of a coun- try more rapidly than is possible with a force of this size, it is better to increase the number of units than to alter materially the proportions between the different groups of employes com- posing each unit. The maximum number of employes in one unit of working force was reached in one of the West Indian colonies during the first half of 1916. Here the force consisted of one medi- cal director, four clerks, five microscopists, twelve nurses, thirty-one assistant nurses, and three caretakers, — a total of fifty-six persons. This force was maintained at a monthly cost of ^1,346.21. Not all of these fifty-six persons were engaged in the work conducted from the central office, small dispensaries having been established at various points, where micros- copists, nurses, and their assistants carried on their duties with occasional visits from the director. The results of this experiment, and of other experiments similar but of smaller scope, show very clearly that it is not advisable to enlarge the force and to increase the area of operation to undue dimensions if the campaign is to re- tain those characteristics which justify the term "intensive." Rather, the object should be to organize a well-balanced force and to concen- WORKING FORCE 39 trate its efforts on a comparatively small area and small population, in order to accomplish the end quickly and pass to a new area. Such a course permits the medical director to super- vise every detail of the work, and to have inti- mate daily knowledge of every important occur- rence. This detailed supervision by the di- rector is very essential, since in the West Indies he must operate in every instance with a force locally recruited, whose members have had no other special training for the work than that which he is able to give them; and this train- ing can be made effective only in so far as the medical director can supervise their work. 20. Branch Offices in Area. The establish- ment of branch offices at various points through- out the area, for doing microscopic work or as a rendezvous for nurses engaged in giving treat- ment, has not led to efficiency in any instance. It seems rather to invite the forces stationed at these remote points, free from the surveil- lance of the medical director, to follow their own devices. Certainly, if the results of mi- croscopic work are to have more than doubtful value, that work should be done at the central laboratory under the personal supervision of the director. 21. Duties of the Medical Director. The medical director is the administrative and 40 INTERNATIONAL HEALTH BOARD medical head of the field unit. He directs the work while it is in progress, and is responsible for the results accomplished. He must have control of his force, and must be in position to apply discipline or reward merit without delay and without the intervention of a third party. To command his force and secure efl[icient work, he must have the power to terminate, with legal notice, the services of any undesir- able member. Every subordinate in the West Indies is therefore asked to sign an agreement in which he places himself under the authority of the medical director, and offers to discharge, to the best of his ability, whatever duties may be assigned to him. A copy of this agreement appears in the appendix, page 172.^ 22. Relation of Medical Director to Govern- ment. Inasmuch as the intensive campaign is intended as a demonstration of the possibili- ties of a direct and definite attack upon a pre- vailing disease, both the organization of the force and the direction of its activities must be considered as only a temporary first step toward the establishment of permanent agen- cies which shall in time apply similar or better ^ In this connection it may be stated that the practice of using gov- ernment employes as subordinates in the force, by having them "sec- onded" from government departments to this special service, is open to objection, both theoretically and from experience. WORKING FORCE 4I methods to the control of all diseases. The most successful work, then, is that which brings to the public such keen realization of benefit that it is prepared not only to co-operate in further and more comprehensive undertak- ings of similar nature, but to insist that per- manent agencies be established to continue such work. With this end in view, the medical director should be stimulated to secure the highest degree of efficiency from his force, so that with and through its members he may render the greatest possible service and leave behind him when his work is finished, as a legacy to the government which has welcomed his coming, a public converted to modern ideas of sanitation and the prevention of disease. 23. Relationship of Medical Director to the People. The proper relationship between the medical director and the people is one which can be neither established nor maintained by proxy. Early in the work the medical director visits all parts of the area and becomes per- sonally acquainted with the people. At all times he is accessible to them, and shows sym- pathetic interest in their attitude and view- point regarding the work. Before treatment is given, he calls at the homes of all persons found infected, to ascertain whether or not treatment can safely be administered to them. 42 INTERNATIONAL HEALTH BOARD and also to prescribe the proper dosage. This personal service and attention is a very impor- tant factor in securing the co-operation of the patients in taking treatment until cured. 24. Duties of Clerical Force. The clerical force is needed to record statistics and to for- mulate reports. This work is done under the immediate supervision of the medical director. At least one of the clerks should be a typist. Inasmuch as the nurses work on Sundays and have Wednesdays off, they leave their treat- ment books in the office on Wednesdays, when the clerks transfer from the nurses' books to the case-record book retained in the office, all data which have not previously been entered in the case-record book.^ 25. Duties of Chief Clerk. The chief clerk is in charge of the stock of drugs and specimen containers, and issues supplies of these items to the nurses as required. Each nurse is charged with the supplies issued to him, and is provided with a locker in which to store them. On Wednesdays, when the nurses are off duty, the amount of supplies used by each nurse, as shown in his reports, is deducted from the list of supplies issued to him, and the con- ^ For a discussion of the methods used in recording and reporting information, as well as for samples of the various forms used, see pages 123 to 164. WORKING FORCE 43 tents of his locker are checked with the re- mainder. In this way it is possible to account for all supplies issued. After checking the reports of the nurses, the chief clerk makes out and posts in the office a sheet showing: (a) the number of treatments given by each nurse during the past week; and (b) the total num- ber of treatments to date given by each nurse in his district. The names of the nurses appear on this sheet in the order of their merit and efficiency as shown by the number of treat- ments they have given. This stimulates inter- est and a wholesome spirit of rivalry, and leads to more efficient service. 26. Duties of Chief Microscopist. The chief microscopist is held responsible for all the work of the microscopic department. In addition to instructing new men, he verifies and records all findings of his assistants, and checks up their daily reports. He receives the specimens brought in by each nurse, gives the nurse a receipt for them, and reports to the medical director the failure of any nurse to get speci- mens at the proper time for first examination or for re-examination. It is his special duty to see that the nurses are informed promptly of the results of re-examination, so that there may be no delay in the course of treatment. He is held responsible for the scientific equip- 44 INTERNATIONAL HEALTH BOARD ment of the laboratory, and for maintaining the methods and technique prescribed by the medical director. 27. Duties of Microscopists. The micros- copists examine, according to the technique and laboratory procedure prescribed by the medical director, all specimens submitted to them by the chief microscopist. They aid the chief microscopist in keeping a record of all specimens coming into the laboratory for ex- amination and in preparing the daily and weekly reports of the work of the department, and they perform any other duties which may be assigned them by the medical director or the chief microscopist. In the early part of a campaign they often help in taking the census, and when not otherwise engaged assist in the clerical work. On Wednesday of each week, in the absence of the nurses from duty, the microscopists finish any laboratory work which may be waiting, prepare a week's supply of magnesium sulphate solution, and clean their laboratory equipment. 28. Selection of Microscopists. In choosing microscopists, preference is given to men be- tween twenty and twenty-five years of age. Probably the best class available in the West Indies consists of natives of East Indian par- entage, who, having profited by the educational WORKING FORCE 45 advantages of the local schools and institutions, are above the average in intelligence. They are quick to learn, and accurate and rapid in their work. Members of the black or colored races are also employed. 29. Training of Micro scopists. It is seldom possible to secure men for microscopists who have had previous laboratory experience. The medical director therefore has to train his force of microscopists when the work is begun in each country. Since the technique and labo- ratory procedure are not elaborate and lend themselves particularly well to the training process, the men soon acquire the necessary skill to distinguish the ova of various intestinal parasites. As early as practicable, the most intelligent and most skilful of the microscopists is made chief microscopist, and later, when he has fully proved his skill and fitness, the train- ing of new men engaged to examine specimens devolves upon him. 30. Duties of Nurses. As stated on page 26, the area of operation is divided into dis- tricts, each of which is placed in charge of a nurse. This nurse takes a census of the people in his district, recording in his census book such facts as are required. While taking the census he delivers to each person a tin container properly marked with his name, age, and house 46 INTERNATIONAL HEALTH BOARD number, at the same time giving directions as to how the specimen of feces to be placed in the container shall be prepared, and stating that on the following day he will call for the specimen. On his first visit to each house the nurse inspects the sanitary accommodations and enters in the census book the conditions found. On later visits he collects specimens and delivers them to the laboratory for ex- amination. As the specimens from people in his district are examined, he is informed of the results, and records in his treatment book the names of all persons found infected. He then calls upon each of these persons and arranges the day of the week upon which that person will take treatment, as well as the day upon which the medical director may call and ex- amine him. Treatment is then administered according to the instructions issued by the medical director.^ In work by the intensive method it is re- quired that each patient be treated once weekly, on the same day of the week, until cured. To make this possible the patient is re-examined on the seventh day after treat- ment. It is the duty of the nurse to secure specimens for re-examination seven days after ^ For a detailed discussion of the method of treatment, see pages 69 to 94. WORKING FORCE 47 the second treatment, and seven days after each successive treatment until the patient has been cured. So few persons are cured by one treatment that no re-examination is made after the first treatment. The nurses are expected to administer per- sonally every dose of medicine necessary in the treatment, and to keep in close touch with the patients on the day of treatment. They are responsible for all supplies issued to them. Once weekly they must account for these sup- plies, and the value of any shortage not ex- plained satisfactorily is deducted from their wage. They are required to make a daily and weekly report of their activities. Sunday being a day of idleness, many people elect to take treatment then. This requires that the nurses work on Sunday, in consequence of which Wednesday of each week is given them as a rest day. 31. Duties of Chief Nurse. Usually the most skilful of the nurses is placed in charge of his fellow-workers. His principal duties are: (i) to visit the various nurses' districts, making inquiry of the people to ascertain if the census has been properly taken, if speci- mens are being obtained from every individual at the proper time, and if treatments are being given regularly and correctly; (2) to visit and 48 INTERNATIONAL HEALTH BOARD attempt to secure the co-operation of malcon- tents among the people; (3) to see whether specimens are being collected for re-examina- tion at proper intervals after treatment; (4) to keep account of the medicine issued to each nurse, and, by checking off the total used at the end of the week, to ascertain if the quan- tity remaining is correct; and (5) to call to the attention of the medical director any irreg- ularity, or any matter requiring his personal attention. These duties are very important and for this reason the chief nurse should be a very trustworthy person. 32. Selection of Nurses. The nurses, like the microscopists, are recruited locally. They may represent any one or several of the dif- ferent elements of population. They are men usually older than those employed as micros- copists, and are often of the schoolmaster class. Generally they have had no previous experience in caring for the sick. They should write legibly and should possess sufficient cleri- cal ability to enable them to take the census and to keep their treatment record books. Above all, they should be trustworthy, for they must discharge their duties, most impor- tant in nature, in the field, where they cannot be always under the eye of the director. The employment of young, immature nurses WORKING FORCE 49 because they may be had at small salaries is a very doubtful economy. To entrust to any but the best type of men available the important duties performed by the nurses is to endanger the success of the work. The nurses should be mature men, with a history of honesty and faithfulness to duty in previous services, and should be permanent members of the force so long as they perform the duties expected of them. The experiment has been tried of em- ploying schoolmasters and others for a por- tion of each week, for a few hours of each day, or for a few days during the height of a cam- paign. In several instances the results have been far from satisfactory. They are not under the discipline and control of the medical di- rector, and have little to lose if their services are found unsatisfactory. Consequently they show only a selfish interest in the work. 33. Training of Nurses. The training of the nurses in the administration of salts and thymol or chenopodium is not a difficult matter, as unusual skill is not required to employ these comparatively safe drugs, and as a safeguard against unpleasant accidents, the medical di- rector is always near at hand to be summoned in those rare cases where disturbing symptoms develop. In the thousands of cases treated in the West Indian colonies we have never had 50 INTERNATIONAL HEALTH BOARD serious symptoms produced by thymol, — the drug of our choice. The practice of our di- rectors of making a personal cHnical examination of every infected person, to test the heart and lungs by stethoscope and by percussion, and also to prescribe the proper dose of thymol for each, probably accounts in large measure for this freedom from serious symptoms. When new men are taken into the nursing force, the medical director delivers a series of short lectures to give them a practical working knowledge of their duties, especially those con- cerned with the art of approaching the people and of gaining their confidence and co-opera- tion. In addition, these lectures deal with the method of administering thymol, with its contraindications, its toxic effects, and with the simple antidotes which ordinarily will re- lieve these effects. A clear and non-technical account of the life history of the hookworm, emphasizing the close relationship of soil pollu- tion to the spread of the infection, is also given. Before a recruit to the nursing force is given a position as nurse, with responsibilities of his own, he is required to spend at least a fortnight in observing the work of other nurses in the field. 1 ^ Special instructions issued to nurses by the medical director appear in the appendix, section V. WORKING FORCE 5 1 34. Duties of Caretakers. The caretakers are generally boys or women who are employed to sweep, wash slides, bury refuse, and run errands. They may be hired at very moderate salaries. 35. Salaries of Subordinate Employes. In the West Indies a maximum salary of ^50.00 a month has been fixed for the chief clerk, and a correspondingly lower sum for his assistants. The maximum for the nurses and microscopists has been fixed at ^40.00 a month, but they re- ceive this only after a considerable term of faithful and efllicient service. Only a small part of the microscopic and nursing force in the West Indies has yet reached the maximum wage. Though these salaries may seem small, it should be remembered that conditions in the West Indies are quite different from those in most other countries, and that living expenses are comparatively very low. The salaries paid our em^ployes are above those which usually they could earn in any other line of work, and we have had no difficulty in hiring men of the right type on these terms. 36. Allowances for Subordinate Employes. No subordinate employe is paid any allowance for travel, for sustenance or quarters, or for any other purposes. In all instances allow- ances for such items are reckoned and included 52 INTERNATIONAL HEALTH BOARD as part of the salary. For a certain monthly payment each employe must render satisfac- tory service, and must provide himself at his own expense with a bicycle or such other means of travel as may be judged necessary by the director. This arrangement relieves the direc- tor and the clerical department of the necessity of keeping numerous petty accounts, and greatly simplifies the question of remuneration for the force. VI CENSUS TAKING 37. Necessity for Accurate Census. To make effective any plan for the complete relief and control of hookworm disease, it is neces- sary to secure a correct census which will embrace all individuals within the field of opera- tion; to record the personal history of each individual as to name, race, sex, and age; and to number or mark each house, making this number a part of the record, so that every indi- vidual may be located at any time. This cen- sus is taken by the nurses. It is a decided economy in time if the nurses, when they are taking the census, also deliver to each indi- vidual a specimen container marked with his name, age, and house number, and request him to prepare a specimen of his feces which will be called for on the following day. A survey of latrine conditions at each home is made at the same time the census is taken, and is included as a part of the census report. By this means the sanitary problem of the area is at once determined. 38. Method of Taking Census. In carry- ing out the work of census taking, the procedure has been to have the nurses devote the forenoon S3 54 INTERNATIONAL HEALTH BOARD to collecting specimens from individuals visited on the previous day, and the afternoon to tak- ing the census and giving out containers at other homes. As early as practicable in the work, the nurse is required to prepare a map of his district showing by number the location of each house. When these local maps are all in, a large map of the entire area of active operations, to be retained for reference in the office, is prepared from them. Small books are prepared for the use of the nurses in taking the census. These are of such size and number that at the end of each day's work the book used on that day may be left at the central office for the purpose of transcribing the data in the permanent record book (see sample page of census book, pages 124 and 125). VII MICROSCOPIC LABORATORY 39. Importance of Laboratory Work. In a campaign against hookworm disease the mi- croscopic laboratory furnishes information which is the basis for every other phase of the curative work. It is here that we discover in the begin- ning those who are infected, and hence, those who are to be treated; and that later, at the conclusion of the treatments, we determine who have been cured. Work so important and upon which so much depends deserves the utmost care and attention to detail. 40. Variations in Microscopic Technique. In our work the diagnosis of hookworm infection is based upon the presence of hookworm ova in the feces of the host. This presence can be determined most readily by microscopic ex- amination. The methods used in preparing the feces for examination and the technique of examination followed are therefore important considerations. Many techniques have been devised for the examination of feces for parasitic ova. All are directed to the same end, but not all are equally accurate nor suffi- ciently practicable for our purposes, which involve the examination of thousands of speci- mens under conditions often far from ideal. ss 56 INTERNATIONAL HEALTH BOARD Concentration is a common characteristic of nearly all these methods, and is attained, re- spectively, by comminution of the feces, by the use of sieves, by sedimentation, centrifug- ing, or by washing in water. Before any method of concentration can be employed, the fecal mass must be broken up, to set free the em- bedded and adherent ova, and water or some other agent must be added to obtain fluidity. In the work in the West Indies in which the International Health Board has participated, unusual difficulties have had to be met in organizing a laboratory force and in selecting a technique which would promise accuracy in results. It was necessary to have: first, a method that was rapid without sacrifice of accuracy, so that large numbers of specimens could be handled at a minimum cost; second, a technique that was simple, requiring the minimum of skill on the part of laboratory employes, none of whom, as a rule, had had previous experience or training in such work, and so had to be taught all that it was neces- sary for them to know; and third, a procedure whereby every fecal specimen submitted would be so handled that the microscopic findings would be the result of the inspection of two or more microscopists, one of them an expert. The last feature was intended to eliminate MICROSCOPIC LABORATORY 57 the element of error which always exists to greater or less degree in individual effort or research, and to place an effectual check on the more insidious harm often resulting from the employment of careless or dishonest persons. 41. Original Technique in British Guiana. In our first work in British Guiana in 1914, our technique of examinations was that given by Dock and Bass.^ It consisted of the ex- amination of at least three direct smears from each specimen on i x 3 inch microscope slides before negative findings were recorded. We realized that this method permitted many light infections to escape observation and we adopted it only temporarily, as a starting point from which to develop a better technique. Later the accuracy of this direct smear method as compared with that attained by our present method of examination was put to test by certain experiments undertaken in British Guiana ^ and Trinidad.^ In the two colonies a total of 2,134 specimens was examined first by one method and then by the other; 700 specimens in British Guiana and 1,434 1 "Hookworm Disease," Dock and Bass, pp. 159-161. 2 Report of Dr. F. E. Field, Supervising Medical Officer of Anky- lostomiasis Campaign in British Guiana, 1914-1916, I.H.B. ^ Report of Dr. B. E. Washburn, Medical Officer in Charge of An- kylostomiasis Campaign in Trinidad, 1915-1916, I.H.B. 58 INTERNATIONAL HEALTH BOARD in Trinidad. In the test made in British Guiana, five direct smears on i x 2 inch slides were required before a negative finding was accepted ; in Trinidad, three smears on 2 x 3 inch sHdes were required. The result of the 2,134 examinations was to reveal 1,049 posi- tive cases, or an infection of 49.2 per cent. A second examination was then made of the same specimens by our present technique, which will be discussed in detail later and which calls for careful centrifuging of an emulsion of the feces in water as an important step. The result of this second examination was to show 1,277 cases positive, or 59.8 per cent. Thus, there was a difi^erence of 10.6 in the percentages of infection found by the two methods, which, as an element of error chargeable to the direct smear method, indicates that its exclusive use is not desirable.^ In the three years which have elapsed since our first organized operations in British Gui- ana, we have extended our work to Trinidad, Grenada, St. Vincent, St. Lucia, Antigua, Bar- bados, Tobago, Dutch Guiana, and the Cay- man Islands; have examined thousands of persons; and have made a constant effort to develop a microscopic technique which would ^ See table on page 64 showing results obtained in Trinidad in examining the specimens of 1,434 persons by the two methods. MICROSCOPIC LABORATORY 59 meet every demand. What measure of success has rewarded this effort may be determined by a perusal of the following pages, in which the details of our laboratory work are set forth. 42. Standard Technique of Intensive Method. All specimens collected are brought to the lab- oratory by the nurses. When a nurse brings in specimens from his district, the chief micros- copist receives, counts, and checks them with the census list presented by the nurse, and acknowledges their receipt by initialing the nurse's list. Until they are to be examined, the specimens from each nurse's district are kept on separate shelves in a case prepared for this purpose. When the specimens are ready for examination, the chief microscopist takes those from a single district, and, arrang- ing them on his table or desk, — which should be high enough for him to stand while at work, — records on the microscopic report sheet ^ the data appearing on the top of each speci- men container. The chief microscopist has on his table microscope slides, flat wooden tooth- picks, and a dropper-bottle containing water. The assistant microscopists are seated at three small tables just behind him. There should be sufficient space between the tables of the microscopists to allow the chief microscopist ^ See form, pages 132-133. 6o INTERNATIONAL HEALTH BOARD to pass freely in his inspections to verify the findings of his assistants. The chief microscopist takes the first speci- men recorded on his sheet and prepares three smears from it, each on a 2 x 3 inch slide, using water as a diluent and spreading the smear evenly with a toothpick, which he discards when the third slide is prepared. No cover glasses are used. He then gives one of the smears to each of his assistants, who at once examines it through his microscope. While the assistants are doing this the chief micros- copist proceeds to prepare three smears in the same way from the next specimen on his list. If, during the examination of the slides, a microscopist discovers a parasite egg or larva, he attracts the attention of the chief micros- copist, who examines, verifies, and records the finding without announcing to the other microscopists what it is. If the first finding is a hookworm egg or larva, the chief micros- copist allows this assistant and the others to continue their search only until he has prepared three smears from the next specimen. But if the finding is other than a hookworm egg or larva, the examination continues until the possibilities of the three smears are exhausted. If all three smears are found negative to hookworm infection, the specimen from which MICROSCOPIC LABORATORY 6 1 they were prepared is set aside for centrifuging later. In determining the length of time to be devoted to the examination of each speci- men, it should be kept in mind that this first examination need not be exhaustive, because it is not final except for positive results; it is mainly to eliminate specimens representing heavy infection, which, because of the numer- ous ova present, do not need to be centrifuged for an accurate diagnosis to be made. 43. Advantages of Standard Technique. The method set forth above has several advantages worthy of mention: first, as already pointed out, each finding being verified by the chief microscopist before being recorded, individual error is eliminated and our results are protected from harm at the hands of careless, unskilled, or dishonest employes; second, in the interval of several minutes which must occur between the first finding and the end of the period allotted to the examination of each specimen, the three microscopists are busily engaged in further examination of their respective slides, thus increasing the likelihood of corroborative findings and rendering more conclusive our data regarding the incidence of intestinal para- sites other than the hookworm; and, third, by giving each microscopist a distinguishing num- ber or letter and by using this instead of a 62 INTERNATIONAL HEALTH BOARD mark to Indicate positive findings on the mi- croscopic report sheet, it is easy to compute at the end of the day the total positive findings of each microscopist, and thus arrive at the relative efficiency of the men. 44. Modified Technique to Facilitate Proc- ess of Examination. If the above method should prove too slow, as it may In some stages of the campaign when large numbers of speci- mens are coming in daily, the following modi- fication, which will permit more rapid work and at the same time will not affect the ac- curacy of the results as to hookworm infection, is recommended. The chief microscopist. Instead of preparing three smears from one specimen, each smear to be examined by a different microscopist, pre- pares one smear from each of three specimens, giving a smear to each microscopist for exami- nation. In first examinations in localities where there is an average rate of infection correspond- ing to that in the West Indies, at least two of these three slides will be immediately found positive to hookworm; and these findings, on being verified by the chief microscopist, can be recorded and the examination of other specimens be undertaken at once. It is pro- posed In this modification that the chief mi- croscopist shall verify every positive finding MICROSCOPIC LABORATORY 63 as before, but it is not proposed that all three microscopists shall each examine a smear from every specimen. By this modified method the data secured regarding the incidence of parasi- tic infections other than hookworm are not so conclusive as when the original procedure is followed. In all instances in the first examination of each person — that is, in examinations before the administration of any treatment — at least two negative smears are considered necessary to determine the need of centrifuging a speci- men. By far the greater number of positive findings are made on the first] smear examined before centrifuging. A few, however, are made on the second smear. Hence, by examining two smears from each specimen we are sure to reduce to the minimum the number of speci- mens to be carried through the more compli- cated and more time-consuming process of centrifuging. 45. Average Findings on Successive Slides Examined. The following table shows in detail the average number of positive findings on each slide examined with the technique here set forth : 64 INTERNATIONAL HEALTH BOARD Table III — Results Obtained on Each Smear Before and after Centrifuging, in Examining Speci- mens from 1,434 Persons in Trinidad. (Note: To diagnose the specimens submitted by these 1,434 P^f" sons, 4,614 separate microscopic examinations were required.) Per cent Examined Positive Positive Negative Before centrifuging First smear 1434 609 42.4 825 Second smear 825 132 9.2 693 After centrifuging First smear 693 109 7.6 584 Second smear 584 45 3-2 539 Third smear 539 539 Total 895 62.4 46. Preparation of Specimens for the Cen- trifuge. When twenty or more specimens have been found negative in the first examination, they are prepared for the centrifuge. The cen- trifuge used is a special machine suppHed by the Bausch and Lomb Optical Co., of Roches- ter, New York, U.S.A. ^ It is hand-driven, with two speeds, and has a Stewart panhead carry- ing twenty tubes. The tubes, of glass, are open at both ends, but are closed with corks when the machine is in use. The method of preparing specimens for cen- trifuging is as follows: ^ For description, see page 176. MICROSCOPIC LABORATORY 65 (i) On a heavy piece of cardboard 14x16 inches in size, preferably with rough or matte surface, twenty z" squares are ruled and num- bered from one to twenty. If the upper sur- face of the cardboard can be rendered water- proof by the application of a coat of varnish or oil, it can then be cleaned after use by wip- ing with an antiseptic solution. (2) Twenty of the specimens to be centri- fuged are arranged on this chart, one in each square. The number of the square in which the specimen is placed becomes the centrifuge number of that specimen and is so recorded on the microscopic sheet. Beginning with speci- men No. I, the following steps are taken in preparing the specimens for centrifuging: {a) The specimen as it rests in the tin con- tainer is thoroughly stirred with a wooden toothpick to secure a uniform distribution of ova in the fecal mass. When the specimen is too dry or too firm for this to be accomplished satisfactorily, a small quantity of water may be added. (^) Small particles of feces are lifted with a wooden toothpick from a number of places in the specimen and placed in a flat-bottom glass vial. The quantity of feces used should be from 4 to 5 grams. To this should be added ten or more times its bulk of water. The water 66 INTERNATIONAL HEALTH BOARD and feces are then stirred and agitated together until an emulsion is formed. (c) This emulsion is then poured into a cen- trifuge tube through a glass or special paper funnel, in which are placed two or three layers of gauze. The purpose of the gauze is to re- move the larger particles from the emulsion. The clips holding the tubes in the panhead of the centrifuge are numbered from one to twenty. The centrifuge tube containing the emulsion from specimen No. i on the chart is placed in clip No. I in the centrifuge, No. 2 in clip No. 2, and so on. When all twenty of the tubes are in position, the top of the panhead is screwed on. The handle is attached first to the low and then to the high speed shaft, until the desired rate of revolutions is attained. With the cen- trifuge described, the length of time necessary to throw most of the eggs suspended in the emulsion to the outer end of the tube and de- posit them on the cork, is two or three min- utes. The time, of course, varies somewhat with the thickness or density of the emulsion. When the process of centrifuging is complete, the tubes, beginning with No. i, are taken out of the panhead, the cork in the inner end of each tube is removed, and the liquid portion is carefully poured off. Afterwards the outer cork is removed, and from the debris which MICROSCOPIC LABORATORY 67 is found deposited on it, three slides are pre- pared and examined by the method previously explained. 47. Technique of Examination Following Treatment. As the intensive method aims at writing "cured" after the name of every in- fected individual in the area of operation, re-examination after treatment, to ascertain whether or not a cure has been effected, is an important step and deserves special considera- tion. It is in re-examinations, where the num- ber of worms in the intestinal canal has been reduced by treatment and where purgation incident to the treatment has swept out any accumulation of ova, that exceptional care must be taken to guard against misleading negative findings, and it is in this phase of the laboratory work that the use of the centrifuge is most helpful. As the first and each succes- sive treatment reduces the number of worms in the intestinal canal and hence the proportion of ova in the fecal specimens, the number of positive findings possible without the use of a centrifuge is correspondingly lowered. Hence, after two treatments have been administered, it is a waste of time to examine more than one smear from each specimen before centrifuging, while some of the directors dispense with all direct smear examinations after two treat- 68 INTERNATIONAL HEALTH BOARD ments and make centrifuging the first step of all re-examinations. So few cases of hookworm infection are cured with one treatment that no re-examinations are made until a sufficient interval has elapsed after the second treatment. 48. Number of Specimens Examined Daily. A laboratory with four skilled microscopists — that is, a chief microscopist and three assist- ants — should handle from two hundred to three hundred specimens daily, according to the percentage and severity c^ infection. Where the rate of infection is low and the disease mild in form, the proportion of specimens re- quiring centrifuging is higher and progress is correspondingly slower. VIII TREATMENT 49. Thymol Preferred as Anthelmintic. Al- though tests of other drugs have been made in the work against hookworm disease in the West Indies, thymol remains the drug of our choice. Two plans of administering it have been tried, — the daily-dose, and the intensive, or weekly- dose, methods. 50. Daily-dose Method of Administering Thymol. This method has been successfully used by Dr. J. E. A. Ferguson, District Medical Officer, in treating indentured labor on the sugar estates of Peter's Hall district, British Guiana. It requires that the patient be given a small dose of thymol daily except Sunday until cured. The dose of thymol for the adult is ten grains, and for children proportionately smaller. No purgation and no modification of diet or habits is necessary except abstinence from alcoholics for a few hours after taking the thymol. In our experiment with this method, we treated 1,876 cases out of a total of 1,918 found infected in a population of 3,207. Thymol distributors visited the infected persons six days in the week and administered the daily dose of thymol. It was not found difficult to 69 70 INTERNATIONAL HEALTH BOARD induce most of the patients to begin treatment. In fact, since the examination and treatment were free, many were eagerly responsive to the idea of "getting something for nothing/' and all seemed to covet the "certificates of health" which were issued to those who were not infected with hookworms, or which were prom- ised to those who, if infected, would persist in being treated until cured. The fact that this method of treatment did not require the patients to make any sacrifice in diet or habits was a persuasive talking-point in inducing the infected to begin treatment, but this advantage was more than lost when it was learned that thymol was to be given them daily for months. Our experience with this method continued for nine months, at the end of which the rate of infection in the area where the plan was used had been reduced from 69 to 31 per cent. To accomplish this reduction, 148,821 doses of thymol were given. The amount of thymol necessary for a cure in individual cases ranged from 250 to 2,000 grains. It was from the prolongation of treatment that most of our difficulties with this method arose: a considerable number became tired of the daily dose and were inclined to abandon treatment, the improvement in physical con- dition being so slow that often it was not suffi- TREATMENT 7 1 ciently apparent to encourage them to continue. During the nine-months' period, unavoidable circumstances — such as absence from home, intercurrent illness, etc. — caused frequent in- terruptions in the course of treatment, and since the efficiency of this method seems to depend somewhat upon its regularity, this added to the difficulties. Also, the rather elab- . orate force required for the distribution of daily doses of thymol to a large population, the great prolongation of the course of treat- ment, and the large amount of thymol neces- sary to cure the average individual, placed the per capita cost too high for the method ever to be used extensively except possibly where the persons to be treated are under strict con- trol, as in certain public institutions, or, as is the case in treating indentured labor, where a force already in existence for other purposes may be employed to distribute and administer thymol. 51. Intensive, or Weekly-dose, Method of Administering Thymol. This is the method used almost exclusively throughout the West Indian colonies. It provides that the patient be given a dose of thymol on one day of each week until he has been cured. The dose is based upon sixty grains as the maximum for an adult, and is preceded and followed by an 72 INTERNATIONAL HEALTH BOARD active saline purgative, the patient being re- quired to abstain from food for at least eighteen hours during the treatment. When the medical director visits the infected people in their homes before they are treated, he subjects each of them to a thoracic exami- nation with the stethoscope and by percussion, and observes their clinical aspects. The infor- mation gained by this examination enables him to prescribe the proper course of treatment and dosage for each individual and to eliminate those medically unfit for treatment. 52. The Medically Unfit for Treatment. Per- sons medically unfit for treatment include those suffering from acute diseases, such as malaria (febrile stage), fevers of any type, diarrhea, dysentery, gastritis, etc.; those having chronic dysentery or diarrhea, organic cardiac or renal disease, pulmonary tuberculosis beyond the incipient stage, or general anasarca; those who are extremely weak or feeble from old age or from other cause; and pregnant women, or women with serious hemorrhagic diseases of the uterus. Patients having these complications should not be treated for hookworm disease, except possibly under hospital conditions. 53. Directions for Taking Thymol. The fol- lowing directions are given to each patient to be followed in taking treatment: TREATMENT 73 (i) At 5 or 6 P.M. on the day preceding the treatment take a cathartic dose of sulphate of magnesia. No supper should be eaten. The saline should thoroughly empty the alimentary canal. (2) Remain in bed the following morning without food, and at 6 a.m. take one-half of the thymol. At 8 a.m. take the remainder. (3) Take a cathartic dose of sulphate of magnesia at 11 a.m. This should be repeated if a thorough movement of the bowels is not secured within two hours. (4) No food should be taken until after the bowels have moved thoroughly, and then no greasy foods or milk should be taken, or alco- holic drinks indulged in. (5) The usual diet and habits may be resumed on the day following the treatment. (6) If a feeling of weakness or dizziness arises during treatment, take one-half cup of strong black coffee without sugar or milk. (7) Careful examination of the dejecta from the second dose of sulphate of magnesia will show the dead worms. There is a scientific reason behind each step of the treatment as detailed by these directions, which must be evident to the mind of the medi- cal man familiar with the disease. Since hook- worm is a disease which will not yield to 74 INTERNATIONAL HEALTH BOARD haphazard medication, some cases proving obsti- nate under any method of treatment, and since thymol is a drug which must be given under certain restrictions in order to be safe and efficient, it is well to have definite directions to follow in its administration. 54. Interval between Treatment with Thy- mol and Re- examination. Early in the dispen- sary work in the Southern States the plan of giving thymol treatment every week was adopted, and in the main has been adhered to since. This practice requires that all re-exami- nations be made on the seventh day after treatment. This interval of seven days be- tween treatment and re-examination is probably not of sufficient length to place above sus- picion all negative findings so recorded, inas- much as the female worms not expelled by the treatment are to greater or less degree subjected to the toxic effects of the thymol, and cease egg-bearing for an undetermined length of time. Hence, absence of ova from fecal specimens collected from a patient too recently treated is not conclusive evidence of cure. To ascertain the proper interval between treatment and re-examination where thymol is used, several of our medical directors have ex- amined a series of cases at different intervals after treatment. These investigations have es- TREATMENT 75 tablished the belief that very few cases found negative on the seventh day after treatment with thymol will be found positive if re-ex- amined at the end of a longer interval. The fact that a small percentage will, however, has led certain of the medical directors to obtain a second specimen for re-examination seven days after the first negative specimen was obtained, and to pronounce no patient cured until at least two specimens — one obtained seven and the other fourteen days after the latest treat- ment — have been found free of ova. 55. Number of Thymol Treatments Neces- sary to Cure. Several of these courses of thy- mol given at weekly intervals are usually neces- sary for a cure. Where the alimentary canal is thoroughly cleared out by salines before the administration of the thymol, and the patients abstain from food and receive the second dose of saline at the proper time, we have a right to expect 50 per cent of the cases to be cured with two treatments. In our four years' experience in the West Indies any marked decrease in this percentage has invariably meant either faulty preparation of the thymol or its improper ad- ministration. This means that about half our cases are cured with two treatments, or in eight days after the first examination. Only a small percentage require more than three treatments. 76 INTERNATIONAL HEALTH BOARD Almost any person who is convinced that he harbors hookworms in his body will readily consent to give one day of each week for two or three weeks to be cured of this malady. 56. Is Thymol a Dangerous Drug? It has often been stated that the above mentioned dose of thymol is dangerous. In reply to this, I point to the fact that more than a million maximum doses of thymol have been adminis- tered in the United States, and several hundred thousand similar doses in our work in the for- eign fields, to persons of every age, color, race, and physical condition, and that many of these treatments early in our work were taken by the patients in their own homes without super- vision from nurse or physician, and yet with- out fatality or serious physical disturbance of any kind, except in a very limited number of cases where the patients indulged in alcoholic drinks or failed to follow directions in some other important detail. It is extremely prob- able that in a large number of cases the thymol was incorrectly taken, for many of the people were illiterate and otherwise densely ignorant. I fancy there are few drugs in the pharma- copoeia which could stand so severe a test with so few instances of serious toxic symptoms. 57. Preparation of Thymol for Administra- tion. Observations were made by Dr. B. E. TREATMENT 'J'J Washburn, Medical Officer in Charge of the Ankylostomiasis Campaign in Trinidad, Brit- ish West Indies, on the use of thymol alone and in combination with different proportions of sugar of milk. The results of this investiga- tion were as follows: (i) Three hundred and twenty-five patients were treated with pure thymol, finely powdered and encapsu- lated; 41, or 12.6 per cent, were cured with two treatments. (2) Three hundred and fifty cases were treated with a supply of thymol already mixed with sugar of milk and encapsulated by the manufacturer. The thymol was not so finely powdered, and was com- bined with the following proportions of milk sugar: 10 grains thymol to z\ grains milk sugar; 5 grains thymol to 5 grains milk sugar; 2\ grains thymol to z\ grains milk sugar. Most of the treatments consisted of doses of the first proportion, i.e., 10 grains thymol to z\ grains milk sugar. Of the 350 cases treated with this mixture, 'j(i, or 21.7 per cent, were cured with two treatments. (3) One thousand one hundred and twelve cases were treated with finely powdered thymol mixed with equal parts of milk sugar; 546, or 49.1 per cent, of these cases were cured with two treatments. These results are presented in summary form below: 78 INTERNATIONAL HEALTH BOARD Per cent of cures Agent used with two treatments Finely powdered thymol 12.6 Thymol with less than equal quantity of milk sugar 21.7 Thymol with equal quantity of milk sugar. . 49. 1 The dosage of thymol and the method of admin- istration were the same in every instance. All medicine was administered by trained attend- ants, who kept the patients under observation during treatment. Although Dr. Washburn's experiments did not deal with numbers suffi- ciently large to make his results conclusive, his findings have nevertheless been fully substan- tiated by other experiments of a similar nature since made by the medical directors of cam- paigns in other colonies, those of Dr. F. E. Field in British Guiana deserving special mention. Evidently thymol, when combined with an equal quantity of milk sugar and the two thoroughly triturated together, is much more effective than when given alone or in a granular state. This is likely due to the fact that in this combination the thymol remains in a state of fine division until liberated in the stomach, and thus, being more uniformly distributed throughout the bowel contents, comes more intimately into contact with a larger proportion of the worms in the bowel. TREATMENT 79 58. Toxic Effects of Thymol. Thymol Is an irritant to the mucous Hnings of the stomach and intestine, but seemingly only to a very slight degree when those membranes are nor- mal and healthy. With acute, sub-acute, and chronic diarrhea and dysentery, and related troubles, the use of thymol is contraindicated because its effect upon the already inflamed mucous membranes of the alimentary canal is to aggravate the inflammatory processes, much to the discomfort and harm of the patient. Except in the case of a very few persons who, because of an idiosyncrasy, cannot safely take even a small dose of thymol, serious toxic symp- toms develop from its use only when it passes into solution in the stomach or intestine and is absorbed into the blood current. It is said to be only slightly soluble in the normal gastric and intestinal juices, and it is this fact which enables us to give it, without harm to the patient, in the comparatively large doses neces- sary to expel the hookworms. Thymol is soluble in oils and fats, and very soluble in alcohol and its dilutions. The pres- ence in the intestinal canal of either oils, fats, or alcohol along with a large dose of thymol will often, but not invariably, lead to the de- velopment of toxic symptoms. Furthermore, if the dose of thymol used in the treatment of 8o INTERNATIONAL HEALTH BOARD hookworm disease is allowed to remain in the alimentary canal indefinitely, a more or less gradual absorption of the drug may take place, and the patient will develop toxic symptoms. The toxic effects of thymol may be classed under two heads, according to the degree of intoxication: minor symptoms, and serious symptoms. 59. Minor Symptoms of Thymol Poisoning. The minor symptoms include: (j) Muscular weakness and lassitude. Most often these are due to the patient's abstaining from food during the treatment and to the effect of the cathartic doses of magnesium sulphate. Usually, except in the very young and very old, these symptoms, when manifested alone, are negligible. (2) Vertigo, or giddiness. This is usually attributed to the absorption of the thymol into the blood current, with its resultant effect upon the cerebral centers. A certain percentage of the patients treated with thymol experience slight vertigo during the treatment, which is relieved immediately when the patient assumes a reclining position, and disappears entirely when the cathartic, which should always follow the administration of thymol, has emptied the intestinal canal. (5) Gastric and intestinal irritation. This is TREATMENT 8 1 usually manifested by a feeling of heat or burn- ing in the esophagus and stomach, and by colicky pains in the abdomen. These symp- toms are most often of a transient nature, not requiring any special effort at relief. In a small percentage of cases, when the gastric irritation does persist, relief often may be had by giving the patient a glass of soda water (one teaspoonful of baking soda in a goblet of water). If this does not accomplish the desired result and the distress of the patient is severe, one or more tablespoonfuls of milk of bismuth, diluted with twice its quantity of water, will afford relief. (4) Nausea sometimes follows the administra- tion of thymol. This is especially true where the preparatory dose of magnesium sulphate is still active when the thymol is given. By keeping the patient quiet and in a recumbent position, vomiting rarely occurs to the extent of inter- fering with the course of treatment. 60. Serious Symptoms of Thymol Poisoning. When serious symptoms appear, they manifest themselves in several or all of the following phenomena: Vertigo has been mentioned already as a minor symptom, but in proportion as it in- creases in degree, accompanied by other dis- turbing symptoms, it indicates further and 82 INTERNATIONAL HEALTH BOARD increasingly dangerous absorption of thymol into the blood current. It is usually accom- panied by headache, by tinnitus, and by dis- turbances of vision. At first the pulse rate is slowed, but later it may become rapid, thready, and weak. Respiration is slowed, and later may assume a sighing, or Cheyne-Stokes, char- acter. The lips and finger tips become blue. The face is pale and anxious, and may be bathed in a clammy sweat. At this stage there is a decided fall in the body temperature, and the clinical picture is very similar to that of surgical shock or collapse. The patient usually suffers with delirium, and unless reaction takes place here, the cyanosis increases, the circula- tion and respiration are further depressed, the patient passes into a condition of complete coma, and dies. 6i. Treatment of Thymol Poisoning. For the milder forms of toxic symptoms — i.e., muscu- lar weakness, vertigo, slight cyanosis, and slow- ing of pulse rate and respiration, — either no intervention is necessary or the following sim- ple measures suffice: (i) Put the patient to bed and give a cup of strong, hot coffee without sugar or milk. (2) If possible, empty the bowel with a high enema of warm water, or of Senna and salts solution. TREATMENT 83 (3) If the enema does not immediately pro- duce satisfactory results and relief does not immediately follow, give a full cathartic dose of Epsom salts, or of any other active saline, in hot water. (4) Do not at this or at any other stage give castor oil as a purgative, or alcoholics by the mouth as a stimulant. In cases where collapse has already come or seems imminent, resort should be had to more powerful stimulants administered with a hypo- dermic needle. These stimulants, in the proba- ble order of their usefulness in such emergency, would be: Morphia, i/6 gr., with 1/150 gr. Atro- pine; Strychnine nitrate, 1/30 gr. ; Nitrogly- cerin, i/ioo gr. ; or Digitalin, i/ioo gr. (Adult dosage). The patient should be wrapped in blankets and be kept warm with hot-water bottles until reaction takes place. No effort should be spared to empty the bowel thoroughly, and by so doing to stop further absorption of the thymol. The recovery of a patient from even the more severe degrees of thymol poisoning is very rapid, and secondary symptoms, if they de- velop, may be treated symptomatically. Un- suspected organic weakness or disease may accentuate any one or several of the above mentioned symptoms. It should not be over- 84 INTERNATIONAL HEALTH BOARD looked, furthermore, that to thymol are attrib- uted certain powers as an abortifacient in pregnancy, and for this reason it should be given only under proper conditions and with proper precautions when this condition exists. 62. Use of Oil of Chenopodium as an Anthel- mintic. Although in recent years oil of cheno- podium has been growing in favor as a remedy for hookworm disease, the experiments with this drug which have been made in the West Indian colonies have in no instance led to its general use. Various methods have been recommended for its administration, the chief of which are summarized below. 63. Schiiffner and Vervoort Method of Ad- ministering Chenopodium. In this method of treatment by chenopodium, 16 drops of the drug are administered every two hours for three doses. Two hours after the last dose, 17 grams of castor oil, with 3 grams of chloroform dis- solved in it, are administered. It is said that the addition of the chloroform to the castor oil is not strictly necessary, but that it does no harm and increases the percentage of cures. No preliminary purge or restrictions in diet are required. The oil of chenopodium may be given either on sugar or in sealed capsules. The dosage for children is in proportion to body weight rather than to age by years. TREATMENT 85 64. Weiss Method of Administering Che- nopodium. Dr. Weiss, of Sumatra, states that the following method of administration is em- ployed advantageously with the labor on the rubber estates of Sumatra: At I P.M., just after the midday meal, i6 drops of oil of chenopodium are administered. At 2 P.M. and again at 3 p.m., similar doses of 16 drops are given. At 4.30 p.m., 20 grams of castor oil are given, after which the laborer returns to his quarters. No dietary restric- tions are practised, nor is a preliminary purge given. The oil of chenopodium is administered in capsules freshly prepared. In the presence of a high rate of infection and of conditions which favor re-infection, it is the routine prac- tice to administer this treatment twice yearly to all laborers, without microscopic examina- tion or re-examination except in certain in- stances. 65. Method of Administering Chenopodium Recommended by Uncinariasis Commission to the Orient. The report of the Uncinariasis Commission to the Orient contains a valuable contribution to our knowledge of chenopodium and its use in treating hookworm infection. This Commission recommends as the routine treatment for hookworm disease, 1.5 centi- meters of oil of chenopodium divided into three 86 INTERNATIONAL HEALTH BOARD equal doses and administered at hourly inter- vals, the first at 7, the second at 8, and the third at 9 a.m. It believes in giving a light evening meal, followed by a purgative dose of magnesium sulphate, and a very light breakfast, consisting of milk or konje, on the morning of treatment. At 11 a.m., two hours after the last dose of chenopodium has been taken, a purgative dose of magnesium sulphate is again administered. Treatment should not be repeated in less than ten days. After con- siderable research this Commission concluded that magnesium sulphate is a safer and more efficient purgative to use with chenopodium than castor oil, which had formerly been so extensively recommended. The section of their report dealing with this subject has been published in an article en- titled *'The Treatment of Hookworm Infec- tion," which appeared in the Journal of the American Medical Association.^ In this arti- cle the relative value of thymol and chenopo- dium, and the after-effects produced by the use of these drugs, are compared. For the benefit of readers who may not have at hand the full treatise, which was based on a series of 123 cases treated with thymol and seventy-nine ^ February 23, 19 18, vol. 70, pages 499-507. Complete reprints of this article will be sent to all interested persons upon application to the New York office of the International Health Board. TREATMENT 87 treated with chenopodium, the following sum- mary of the conclusions reached by this Com- mission is appended: "It would appear from the comparisons given that the half maximum dose (0.5 c.c. three times, or 1.5 c.c.) of oil of chenopodium is the treatment for recommenda- tion as a routine vermicide. "It does not have the toxic effects of the full dose, and two treatments have the very satisfactory result of removing 99 per cent of all worms present. "It has the additional advantage of a more uniform action, a greater effect on ancylostomes, and of being less unpleasant to take than thymol. "Thymol shows an advantage over this half-maximum dose of oil of chenopodium in that the 90 grains' dosage produces a better result when single treatments are com- pared. This advantage disappears, however, when two half-maximum treatments of oil of chenopodium are given. "Smaller doses compare unfavorably with a single half-maximum dose of oil of chenopodium. A dose as large as 90 grains of thymol, if administered indiscrimi- nately throughout the population, would probably give rise to serious symptoms." 66. Interval between Treatment with Cheno- podium and Re- examination. Certain direct- ors who have used chenopodium extensively report that it inhibits the egg-bearing function of the female hookworm much longer than thy- mol, and that for this reason a minimum inter- val of fourteen days should be allowed to elapse 88 INTERNATIONAL HEALTH BOARD between the treatment of a case with chenopo- dium and re-examination. We have seen that the Uncinariasis Commission to the Orient recommends at least ten days. The directors of work in certain countries allow a similar period to elapse. It was shown, however, by Washburn and by Colwell in their experiments with chenopodium in Trinidad and in Grenada, that even with an interval of fourteen days between treatment and re-examination, there still exists a very material element of error in the negative findings. (i'j. Preparation of Chenopodium for Admin- istration. The fact that flexible gelatin cap- sules do not keep well in tropical climates has led to the practice of giving oil of chenopodium on sugar. This also has its disadvantages. Recently, the ordinary hard, or shell, gelatin capsules have come into use for administering this drug, and are proving quite satisfactory. They are prepared as follows: the required number of minims of oil of chenopodium is placed in the long end of the capsule; the edges of the cap portion are moistened on the inside with water, using a fine camel's-hair brush; the capsule is then closed and the cap portion forced firmly down. To allow the cap to dry in position, the capsules are placed in a rack in an upright position for fifteen minutes. Care TREATMENT 89 should be taken to get no oil on the outside of the long end of the capsule, as otherwise the cap will not adhere properly and the oil will leak out. When the capsules are dry they should be kept in an air-tight container, into which, for its drying properties, a small quan- tity of lycopodium powder may be dusted. 68. Measurement of Oil of Chenopodium. Chenopodium is usually measured either by the drop or by the minim. In testing the rela- tionship of the drop to the minim we find that no two droppers, even of apparently the same make and size, give the same proportion of minims to drops in a cubic centimeter. The slightest variation in the calibre of the tip of the dropper, of the position in which the dropper is held, of the weight of the fluid column in the dropper barrel, of the temperature of the oil, or of the specific gravity of the oil (which varies considerably in different samples), renders the drop a most uncertain quantity. Medical directors should be specially cautioned not to use the drop as a unit of measure. 69. Toxic Effects of Chenopodium. The writer has recently had brought to his notice a considerable number of cases of chenopodium poisoning, only a few of which have yet ap- peared in medical literature. These cases, which unfortunately have not been free from 90 INTERNATIONAL HEALTH BOARD fatalities, have occurred in the Southern States, the West Indian colonies, Panama, Nicaragua, Ceylon, Egypt, and Brazil. In nearly every case the oil of chenopodium was adminis- tered by one of the accepted methods of treat- ment and in less than the maximum dose (of 3 c.c). In most of these cases the alimentary canal was kept as nearly empty as possible for the period of treatment, by restrictions in diet and by purgation; and magnesium sulphate was used as the purgative. This is significant in view of the following statements by Salant and Nelson: ^ "The toxicity of chenopodium is distinctly increased in starvation and is decreased by feeding oils and by feeding a rich carbohydrate diet ..." "The increased toxicity of chenopodium in starvation and its cumulative effect are important factors, as shown in our experiments in determining its toxicity. It is quite possible that the reason there are so few cases of poisoning in the literature is that castor oil has been administered immediately after chenopodium, which is quite likely to exert an antidotal effect on the drug." Attention should be called, however, to the fact that these conclusions of Salant and Nel- son do not agree with the experience of the Uncinariasis Commission to the Orient, which ^ Toxicity of Oil of Chenopodium, by Salant and Nelson, Reprint from American Journal of Physiology, Vol. 36, No. 4. TREATMENT 9 1 found that persons who had taken castor oil " always showed the greater number of cases of dizziness and deafness, most of the cases of inabihty to rise and walk occurring in this group." This Commission reported also that "dizziness and muscular incoordination were less marked with magnesium sulphate than with castor oil." It is reported that in Sumatra several hun- dred thousands of doses of chenopodium have been administered by the method described on page 85 without the development of toxic symptoms. It is interesting to note that this method does not require restrictions in diet; that the persons dealt with normally subsist on " a rich, carbohydrate diet"; and that "cas- tor oil is administered immediately after the chenopodium." The fact that the treatment is given without preliminary microscopic diagno- sis and without microscopic re-examination to ascertain if those treated have been cured, how- ever, makes uncertain its efficacy in curing the patient, although it is said to cause marked improvement in physical condition. 70. Symptoms of Chenopodium Poisoning. These symptoms seem to group themselves under two heads: (i) Gastro-intestinal symp- toms and (2) Neuro-toxic symptoms: (i) Gastro-intestinal symptoms: In many cases 92 INTERNATIONAL HEALTH BOARD where oil of chenopodium is administered there is evidence of irritation to the mucous Hning of the stomach and intestine, manifested by a sensation of heat or burning in the stomach and by coHcky pains which may continue for several days. Nausea and vomiting are some- times present. As a rule, the gastro-intestinal symptoms are not severe and need give rise to no alarm, but in three cases reported recently from one of the Southern States these symptoms de- veloped rapidly, violent retching and purging occurred, and the patients collapsed and died, apparently without any marked involvement of the central nervous system or other evidences of absorption of the drug. (2) N euro-toxic symptoms: Many patients to whom oil of chenopodium has been given com- plain in a few hours of tingling or numb sensa- tions in the extremities. These symptoms may persist for several days, often causing the pa- tient much discomfort and uneasiness. The more severe neuro-toxic symptoms — consist- ing of headache (usually frontal), vertigo, tinni- tus aurium, deafness, muscular weakness, mus- cular incoordination, localized muscular spasms, delirium or mental incoherence, convulsions, and coma — rarely develop in less than from twenty-four to thirty-six hours after the drug has been taken, and have been known to be TREATMENT 93 delayed until the third day after treatment. In most fatal cases reported, these symptoms have developed in the order given, the patient dying in deep coma after a severe convulsive attack. The aural phenomena produced by cheno- podium poisoning are very constant, and often persist for a long period after other symptoms have subsided. Dr. Samuel Seiton of New York reported three cases in which the " anom- alies of audition" were very marked. He inferred "that the medicine had a somewhat specific effect on the middle ear,'* and spoke of the vertigo as being of auditory origin.^ 71. Treatment of Chenopodium Poisoning. Salant and Livingston state that chenopodium depresses the heart's action, causing a marked fall in blood pressure, and that it also depresses the respiratory centers, with resulting decrease in the rate and amplitude of respiration. The character of its toxic symptoms indicates also that it produces a cerebral congestion and has a somewhat selective action on the auditory mechanism. On the development of symptoms of poison- ing by chenopodium, a dose of castor oil should be administered at once, and should be re- ^ American Journal Otology, Vol. 2, 1880, Aural Phenomena of Chenopodium Poisoning, S. Seiton, M.D. 94 INTERNATIONAL HEALTH BOARD peated, if necessary, until the alimentary canal has been thoroughly cleared. This first meas- ure is advisable not alone because it clears the alimentary canal of the drug and prevents further absorption, but also because of the antidotal properties which are attributed to castor oil. The cardiac symptoms may be met with digitalin, preferably administered subcutane- ously. The convulsed condition often met with in these cases does not necessarily contraindi- cate strychnia in small doses as a respiratory and general stimulant. In collapse, the appli- cation of heat to the body and other restorative measures may be employed. That oil of chenopodium will ultimately occupy an important place as a vermifuge is evident to all who have used it for this purpose. It is also evident, and becoming more so with in- creasing experience, that it is a powerful poison, often uncertain in action with our present dosage and methods of administration. To render it safe and efficient as a therapeutic agent, more knowledge must be had as to the proper method of its preparation, as to its chemical composition and stability, and as to its proper dosage and method of administration. IX SANITARY MEASURES FOR PREVENTION 72. Necessity of Preventing Soil Pollution. As the whole question of preventing the spread of hookworm disease is one of guarding against the deposit of ova-impregnated feces on the surface of the ground, where the eggs can hatch and develop into infective larvae, the problem of establishing an adequate and satisfactory- system for the disposal of night soil becomes of paramount importance. In the West Indian colonies this feature of the work is entirely in the hands of the local governments. The Board undertakes merely to locate and to cure, so far as this may be possible, every per- son infected with hookworm disease in the areas of operation, and to educate all of the people — through literature and illustrated lec- tures, and by other means — in ideas of modern sanitation and disease-prevention. 73. How the Sanitary Problem is Defined. The sanitary problem of an area of operation is determined by a house-to-house survey of latrine conditions, and the object in sanitation has been accomplished when every house has been provided with adequate latrine accommo- 95 96 INTERNATIONAL HEALTH BOARD dations and when a system of inspection has been established to guarantee their proper use. The sanitary work, which must be kept under a system of permanent inspection, is carried out by permanent government agencies. Where no sanitary organization exists, the intensive work enables the government to undertake a definite sanitary task on the basis of an insig- nificant outlay and to develop its sanitary organization gradually, as the work is extended from area to area and as the people are edu- cated to the point of giving willing and intel- ligent co-operation.^ The International Health Board does not undertake to advise as to the definite type of latrine to be installed in these areas of opera- tion in the West Indies. The department of health in each country is responsible to its people for all sanitary measures carried out under its direction, and must, therefore, use its own judgment as to the type of latrine recom- mended. 74. T5TDes of Latrines to Prevent Soil Con- tamination. In most instances the pail or pit type, or both, have been adopted. The pail type, under controlled conditions and with proper disposal of the night soil, is safe; but practical experience in rural communities has ^ See Second Annual Report, International Health Board, p. 22. SANITARY MEASURES FOR PREVENTION 97 demonstrated that it frequently becomes offen- sive and falls into disuse, and that extreme difficulty is experienced in keeping the boxes fly-proof and in having the pails properly cleaned. Where the contents of the pail are buried in the soil, this must be done according to careful government regulation, else many consequences may result to defeat the original purpose of the effort. The pit latrine, which has been installed in large numbers in most of the West Indian colonies, has the advantage of being inexpen- sive, simple in construction, and almost auto- matic in operation. It has come into extensive use mainly because it is practical and the people can be induced to install and to use it. Where there are no latrines and soil pollution is the rule, and where the level of the ground water is such as will permit of serviceable pits being dug, the introduction of the pit latrine is a vast improvement, not alone for controlling the spread of hookworm disease but for reducing the occurrence of other excrementitious diseases as well. One should remember, however, that its use involves a large accumulation of excreta underground, with whatever this condition im- plies as to the danger of water contamination by seepage and underground drainage. The finding of a satisfactory method for the 98 INTERNATIONAL HEALTH BOARD disposal of sewage at the rural home, one which the people may be brought to adopt and to carry out, and which will prove to be safe in actual experience as well as in theory, is a problem yet to be solved. X PER CAPITA COST 75. Importance of Cost Element. In con- sidering any plan or scheme which contem- plates an attempt at the relief or control of disease — or, in fact, any undertaking of a public or of a philanthropic nature — the item of cost, except possibly in great emergencies and under special conditions, must receive care- ful attention. The more extensive the field to be covered, the more important becomes this question of the cost of the enterprise. In our campaigns in the West Indies, the item of cost has received special attention, since these efforts are intended to serve as demonstrations which, by proving the feasi- bility of attaining the object in view at a non- prohibitive cost, will lead to the establishment of permanent agencies to continue and enlarge the working program. 76. How " Per Capita Cost " is Figured. When a given piece of work is finished, or at the end of a calendar year, it is desirable to have some index of cost for the year or for the completed work. This index is expressed as the per capita cost of examination, of treatment, or of cure. The index is reached by the simple 99 lOO INTERNATIONAL HEALTH BOARD process of dividing the total budgetary expen- ditures of the campaign by the number of people examined, by the number of people treated, or by the number of people cured, as the case may be. While this is called "per capita cost" for want of a better term, it is understood that it is not the actual per capita cost of any one of these three features of the work, but only an index of cost which for pur- poses of comparison is sufficient. From these indices one gains a rather clear idea of the efficiency of a campaign from the standpoint of cost. It should, however, be kept in mind that no numerical expression can be given to the far-reaching and permanent educational results of successful intensive work. These results can find expression only as the awakened interest and concern of the people lead them, in the future, to protect human life from the baneful effects of disease. 'j'j. Cost Indices of West Indies Intensive Work. The following table shows the cost indices of the campaigns in the West Indies for the period of four years, 1914-1917. It should be noted that the tendency has been downward in spite of the great advance in the cost of medical supplies, of scientific apparatus, and of ocean freights, and the fact that in several instances we are operating in less populous PER CAPITA COST lOI O .£ •> "O y-\ _0 So! o ■ >> L I-4 <■« CD ci-"a o 3 lO «-l T-4 rH C4 lH iH O x-r . u bfi ^ S- s «b c« e^ ^ 04 eq C4 btal red jmb son w >'(3 < H 5 5 1--. r<^ ro o rviir) pq ID vo o OOt^ •>i3 S iq (N r>. p 00 On O lO CN »-< lO CN ^ CN ■-^s o ._( «N|r^ O i^ lo NO =3 in vq p . o\ »-i ' 1-1 c-i T-J »-< »-< '"' VJ. -a (u -73. S o t^ CN O lO Ov LO •^ t^ (u a ^ •<* fO <0 00 O 1-1 t^ o\ ^ »-< X ▼H ■W3. ■^ 4* — o lO 0\ O >0 O . NO »^ •^ ■ 3 OT '"' o On '^ ■* . t^ On »-H *-* u 0\ • -• (u vi ' 1-i ' ' ' T-i ^^ 1) **-• o. o •* p :p ; : : : : Q 0\ ^ ! 1—4 • . ! . ! 2 S 1-1 ■««. O 3 H = lU M— M «o lo M t- t- T}( •* eo 2 <^ !3 fe u. S T-l 00 p 00 0> p p 1-1 1-i ' T-i T-i i-i i-i i-i T-i ^ is >. CO .2 w *-) c • M 3"5 c o C O rt^O «.2 g-^ ( o J "3 O < C t. 3 u • • u 102 INTERNATIONAL HEALTH BOARD areas. This decrease in cost is probably due to improvement in methods, to greater effi- ciency of the field forces, and to more perfect co-operation of the public. It is obvious that the per capita cost of treatment and of cure will be higher in those colonies having light infection: Antigua exemplifies this fact in the accompanying table. XI CONCLUSION 78. Wide Applicability of Intensive Plan. The experiences of four years in the West Indies have demonstrated that the intensive plan of work is feasible under a great variety of condi- tions, and strongly suggest its applicability under all conditions, irrespective of race, creed, occupation, environment, distribution of popu- lation, or degree of infection. Successful work has been done in areas where five different languages were spoken, and where East Indians, negroes, Chinese, Portuguese, and Creoles of English, Spanish, and French blood, with a great variety of mixed breeds, made up the population. The distribution of population has varied from the densely inhabited villages of British Guiana and Trinidad to the scattered and almost inaccessible rural homes of St. Vincent, where, in one instance, with a donkey to ride, a nurse could visit only two homes in a day. It is remarkable that in the sparsely settled areas, w^here travel and the distances between homes render the duties of the nurses so diffi- cult, the per capita cost has not been unduly increased. When we consider that the dangers 103 I04 INTERNATIONAL HEALTH BOARD of re-infection are, from natural causes, much less in sparsely settled sections than in more densely populated areas, where it is corres- pondingly more difficult to secure adequate sanitary precautions against soil pollution, it would seem reasonable to expect that in the sparsely settled sections total eradication will be earlier and more easily reached. While agriculture is the principal industry of the peoples involved in these campaigns, yet a variety of other vocations has had repre- sentation among those treated, and all classes and walks of life are included, from a judge of the supreme court to the humble "squatter" on crown lands. Certainly climatic conditions have not fav- ored the purposes of the work, for in all in- stances we have operated under the conditions common to tropical countries, which are recog- nized as most favorable to the spread of hook- worm disease. What degree of success we have been able to abtain under these adverse and varied conditions is fully set forth on pages 121 and 122. 79. Educational Value of Intensive Meas- ures. The educational value of a demonstra- tion against hookworm disease is often largely determined by the thoroughness, scientific ac- curacy, and efficiency of the methods used, and CONCLUSION 105 is enhanced in proportion as we more nearly accomplish complete control of the disease. In any area of operation the more intelligent classes, consisting of professional men, officials, clergymen, schoolmasters, and plantation own- ers and managers, whose co-operation is so vital to the success of the work, are quite capa- ble of appreciating the difference between thorough and efficient methods and the success- ful handling of the problem, and the opposite; and even the less intelligent and the illiterate are not insensible to the painstaking care and attention given them individually and collec- tively in the effort to cure and protect them from a disease the seriousness of which they soon come to understand. The requirement of the intensive method that every home be visited by the physician in charge, for the purpose of examining the persons to be treated before the drug is ad- ministered, and the subsequent weekly visits of the nurses to give treatment, establish a bond of sympathy and interest which in most instances continues until cures are effected. 80. Intensive Method as Means of Gaining Good-Will of Populace. One of the most valuable features of the intensive method is that it gives the people a minimum of inconvenience and annoyance in examination I06 INTERNATIONAL HEALTH BOARD and treatment. Everything is done for the patient that can be done. His convenience and welfare are made the first consideration. The nurses mark and leave with him a speci- men container; they call for the specimen; they report to him the result of the examina- tion. If he is infected, the medical officer calls upon him, and, after examination, prescribes a dose of thymol and a course of treatment to be carried out by the nurse in the patient's own home on the day of the week best suited to his convenience. He is not asked to leave the familiar surroundings of his home to make repeated trips to some central point or hospital, which often to his simple mind is a place of terror and unknown danger. No essential step of the process, from the recording of his name in the census to his discharge as cured, is left to fortuitous circumstances or his own initia- tive. Although no compulsion is used, he is not asked or expected to exercise discretion in a matter in which manifestly he can have but poor discretion. The attitude of confident expectation of full co-operation which the staff maintains toward the patient goes far toward assuring the needful co-operation. Dr. Washburn, in commenting upon his ex- periences with the intensive method of cam- paigning in Trinidad, British West Indies, CONCLUSION 107 says: ^ "While the primary intent of the inten- sive method is the control and approximate eradication of hookworm disease, beyond this is the purpose that the results of this work shall demonstrate in a striking and convincing way the possibilities of a direct and definite attack on disease in general when both remedial and preventive measures are brought into play. ... In working out these objects [the exami- nation of all the people and the treatment and cure of the infected], many opportunities are afiPorded for demonstrating to the people the chief factors involved in the pollution of the soil and in other health problems. In fact, the chief aim of the intensive campaign is educa- tional. We endeavor to give the people an object-lesson in sanitation, to teach them the basic facts underlying the spread of diseases due to soil pollution. The people and the government may be shown that it is possible to conduct a campaign against hookworm dis- ease in a definite area, with the result of greatly lessening the amount and the severity of the infection and of measurably approaching the complete eradication of the disease. "We believe that this demonstration has been impressive, and will lead to permanent 1 Report of Dr. B. E. Washburn, Medical Officer in charge of Ankylostomiasis Campaign in Trinidad, for the year 1915. I08 INTERNATIONAL HEALTH BOARD results because of the fact that we have at- tempted to do only one thing, and have accom- plished this in a definite manner. To teach a country the story of hookworm disease in all its details and to show it objectively that it is possible for this disease to be effectively dealt with, is much better than to attempt spasmodi- cally to demonstrate the importance of a num- ber of problems of public health." The medical director in British Guiana, Dr. F. E. Field, in his report of November i8, 1914, in commenting on the very successful intensive campaign completed in the Peter's Hall dis- trict, says: "All work recorded in this report has been carried on without interfering with the people's daily work;" and continues, "It is gratifying to report that the local authorities of the various villages of Areas A and B in Peter's Hall district have so thoroughly real- ized the benefits obtained from the expulsion of the hookworm and have come to understand so well the principles of re-infection and the necessity of preventing it, that they have sub- scribed the necessary amount to maintain a sanitary inspector to devote his full time to their district." In conclusion, then, we may say that correct methods of conducting the work inspire con- fidence; that confidence insures co-operation; CONCLUSION 109 and that co-operation brings results satisfying not alone In the cure of the Infected, but In the stimulation among the people of Intelligent interest in all questions pertaining to their health and physical well-being. ILLUSTRATIONS 14 r Fig. 4. Nurses taking treatment to the patients in their homes. St. Vincent fig. 5. Rear view of fig. 4 showing method of carrying drugs and equipment i;il»;^ii't^w'^'ui:"''"''J fig. 6. Group of Alohammedans, all infected with hook- worm disease. Mosque in background. British Guiana Fig. 7. Mohammedan bishop and family. All cured of hookworm disease. Trinidad Fig. 8. A family group. All infected with hookworm disease; all treated. St. Vincent Fig.c). Company of soldiers. Eighty-two per cent infected with hookworm disease. Cured in one month. St. Lucia APPENDICES I RESULTS ACCOMPLISHED Table V on page 122 shows the degree to which our campaigns in the West Indies during the years 1914- 1917 inclusive have approximated the complete relief and control of hookworm disease in the respective colonies. By consulting this table, it will be seen that the per cents opposite the line "Remaining in Area Uncured," as based on the number of persons originally infected, run from 8.0 per cent in Dutch Guiana to 26.1 per cent in St. Lucia, with a general average of 16.9 per cent for the seven colonies represented. With an average of only 16.9 per cent of the original infection remaining in these areas, with the people thoroughly understanding the methods by which the disease is contracted and prevented, with the installation of latrine systems which with continuous government supervision should become increasingly effective, it would seem reasonable to expect that, without a second campaign of treatment, the eradication of the disease in the different areas will be attained by the operation of preventive measures and by the self-limiting character of the infection in the individual. 122 APPENDIX >> 1— 1 .£> ^ »^ U 4) 0\ 1-1 o Q ■'-' •r}< E o\ o !-< ^ « o cO 9- « CKj < a z H 72.1 70.4 7.7 21.9 .4 12.3 6.1 3.1 d 27008 19462 13696 1495 4271 95 2391 1186 599 H Z 66.3 83.2 1.3 16.6 '2^9 4.5 8.1 6 20313 11440 9613 154 1773 330 510 926 < C/3 63.1 68.5 5.4 26.1 ^ 10 00-<1* ^ (N 00 10 < < Z u as u 67.8 74.4 4.1 21.6 .6 4.5 4.7 11.7 d 8236 6683 4166 228 1199 31 254 262 652 S5 H < 90.8 83.6 8.3 8 ^H o» CO t- Ti) ON-* CM LO to to "-^ N CN 00 to \0 0» tNrOt^t^ CO to t-« CO Tl< to to t- i-t 1 165866 97632 73711 7391 16630 206 6159 4561 5542 40 22 -c C 'e X (X. -a 4 t. c e u H -a c c rj < II FORMS USED IN INTENSIVE WORK The information collected in all measures for the relief and control of hookworm disease falls naturally under one of two heads: one relating to what is done; the other, to what is learned. The first object of the work, of course, is to relieve and control the disease; in the at- tempt to do this, however, much information of value in planning further work is incidentally gained. It is necessary to have some systematic method of recording and reporting the results of the work in both of these phases. In addition, it is necessary for the medi- cal director to have, for administrative purposes, certain forms for the use of his subordinates in collecting and presenting to him, daily and weekly, the results and progress of the work in the field. The most important forms used for these several purposes in our campaigns are presented, with explanatory notes, in the following pages: The Census Book (Form 127) The book for the use of nurses in taking the census provides space for recording the house number, name, age, sex, and race of individuals, and the kind of latrine accommodations found at their homes. The classification of latrines as shown on this form is very general, F indicating the absence of any latrine; E a latrine for privacy only, neither preventing soil pollu- tion nor being screened against flies; and D any type of latrine effectually preventing soil pollution and so constructed that it is fly proof. A fourth section is pro- vided for recording types of latrines which may be of 123 124 APPENDIX III 1 I Si til o < X X u IS) 111 < Ul < z HOUSE NUMBER FORMS USED IN INTENSIVE WORK 125 a. < tij a. u z 5 1- l< J u. UJ Q. > Z H U u Q. •J) Z < u I 1- ii. UI Q Z H U U Q. U) Z tf) q: u. C LI I 1- u. 1 u i 1 1 ! ! 1 1 Q o °> O Vm «* .2 CO 2 CJg- O rt i-i a. U^ g s 02 04 126 APPENDIX special significance in the country or district where the inspection is made. Columns are provided for recording the dates when containers are delivered and when specimens are collected, and at the right there is a space for remarks. The census books are usually of a size to accommodate 150 to 200 names. It is not desirable to have them larger, since they must be left at the central office for the purpose of recording the census in the case-record book, and it is better to have each book represent only one or two days' work. The Case-record Book (Form 100) 1. Purpose of the Book. The case-record book has been designed to provide for the medical record of each patient, as well as to give a complete census of the area and a record of the latrine improvement at the homes. By combining into a single book the three records (i) of census, (2) of examination and treatment, and (3) of latrine improvement, much re-writing may be saved. The effort has been made to make the case-record book as compact as possible. There are twenty lines and a total on each page, and the books may contain 100, 200, 500, or more pages. 2. Suggestions for Reporting. A sample page of the case-record book follows. It will be seen that oppor- tunity is afforded for accounting for every person in the area of operation. Opposite the name of each person it is possible to indicate whether or not he was examined, and if not examined, the reason; if infected, whether or not he was given first treatment, and if not given first treatment, the reason; and if given first treatment, whether or not he was cured, and if not cured, the reason. The number of treatments required to cure each person FORMS USED IN INTENSIVE WORK I27 may also be recorded. It is possible in this way to exhibit the thoroughness of the work by showing (i) how many of the persons found infected were cured, and (2) how many of the persons found infected remained in the area uncured at the close of the work. Improvement in sani- tation will be indicated by comparing latrine conditions at each home on the first inspection and on the last. A few remarks concerning the use of each section of the blank are given below: (i) Patient's Number. The first column, headed "Pa- tient's Number," will be filled in when the names in the census book are transferred to the case record. (2) Name. In the column headed "Name" will be entered a complete census of the area. As far as possi- ble the names in this column will be entered by families, with the name of the family-head first. The surname will be followed by the given name. (3) Residence. The column headed "Residence" is for recording the street address of patients living in towns, or facts which may be of aid in locating homes in rural districts, (4) House Number. The column headed "House Num- ber" will be used in countries where, for the sake of convenience, each house is given a number by the census-taker, (5) Sex. In the column headed "Sex" the initials M or F may be used for denoting whether the person is male or female. (6) Jge. The section headed "Age" has five divisions. The exact age of each person will be entered in the column corresponding to the age group to which he belongs. (7) Race. The column headed "Race" has five divi- sions corresponding to the five major racial divisions of 128 APPENDIX mankind. The term "Brown Race" denotes the brown race of Malaya. Persons of mixed blood will be entered according to the predominating element in their blood. A check mark in the proper column will denote the race of each person. (8) Examined. In the section headed "Examined," space is provided for indicating the results of each exami- nation from the first to the eighth. In making the first examination, specimens are usually examined incidentally for other parasites in addition to hookworm. Under "First Examination," therefore, space has been pro- vided for recording the number of specimens either posi- tive or negative to hookworm, together with the number of specimens positive to the other intestinal parasites most commonly found, including Ascaris, Trichocephalus, Strongyloides, Oxyuris, Tenia, and Ameba. In the columns headed "Second Examination," "Third Exami- nation," "Fourth Examination," "Fifth Examination," "Sixth Examination," "Seventh Examination," and "Eighth Examination," space is provided for reporting upon hookworm only. The month and day on which each examination is made will be entered and a check mark used for indicating which parasites are found. When the examination is made on which the patient is found negative to hookworm, the month and day will be entered, and a small "c" inserted in the column headed "Uncinaria" to indicate that a cure has been effected. The addition of these small "c"-s will agree with the addition of the column headed "Cured" found further to the right. It will be noticed that space has been provided in the case-record book for recording the results of eight exami- nations and eight treatments only. In some cases more examinations and more treatments may be necessary. CASE RECOBD i«.t« — >»'• .»,, „ .„„ „ON wc «Kr 0.1 HE p p. .c ONT .0 c F u NC «, s s N OF C WORK ENDED r ...; ■= "■ ••:. ff n H ,.^„ ,-'.:". ,..;•;•.. .;;■.■.•.■. ^.^ 1 1 ^:r- nsn nuzTi — rjirr j^ 1 .. „ 1 ^;_._ t 1 c lillii ffrTr „.^,J',".'""'i us, I.....CTIO, »EM.„KS i "ii if ij 1 i 1 ij f[ "1 i i s 1 1 i 1 I 1 1 1 j 1 1 11 f 1 In 1 i i 1 i 1 1 1 ei.. 1 B.TI 1 »Ti 1 1 T i - 1 1 i III 'i 1 ^ ^ TmO'lATXN. „,. <..... U.iUI,. MTl i 1 f g 1 1 i i h 1 ; " • , ..... 1 5 .. 1 1 i , , .r _ , 3 „ .... -ji- r- « -■!. H .. 1. „ „ - ,^ _ r r - Fig. ji. F age of C ase- Record Book, Form loo. (Reduced facsimile; actual measurement of page, aiixii". For explanation of symbols "D", "E", "F", and "Other," see page 130.) n FORMS USED IN INTENSIVE WORK I29 These may be forwarded to a new page. A note in the "Remarks" column opposite the patient's name will call attention to the record of examination and treatment being continued elsewhere. (9) Not Examined. In the section headed "Not Ex- amined" are four divisions, "Not Located," "Refused," "Removed," and "Died," to be used, respectively, for recording persons who are not examined either because (i) they cannot be located, (2) refuse to be examined, (3) remove before examination, or (4) die. A check mark in the proper column will indicate the reason for any person not being examined. (10) Treated. The section "Treated" has eight sub- headings: "First Treatment," "Second Treatment," "Third Treatment," "Fourth. Treatment," "Fifth Treat- ment," "Sixth Treatment," "Seventh Treatment," and "Eighth Treatment." Under each sub-heading, space is provided for the month and day on which each treatment is administered, and for the number of grains of thymol given. (11) Not Given First Treatment. The next section, "Not Given First Treatment," has five sub-headings: "Not Located," "Refused," "Medical Reasons," "Re- moved," and "Died." These five sub-headings indicate, respectively, five reasons for failure to administer first treatment, as follows: (i) the patient cannot be located after examination, (2) he refuses to accept treatment, (3) he cannot be treated for medical reasons, (4) he has removed before treatment can be given, or (5) he has died. A check mark in the proper column will indi- cate why any particular person has not been given first treatment. (12) Given First Treatment but not Ciired. The sec- tion headed "Given First Treatment but not Cured," 130 APPENDIX with its six sub-headings, "Not Located," "Refused," "Medical Reasons," "Removed," "Died," and "Under Treatment," is for recording persons who are given first treatment but are not kept under treatment until cured. A check mark in the proper column will indicate why any person given first treatment has not been continued under treatment until cured. (13) Cured. The column "Cured" will indicate, by the presence or absence of a check mark, whether or not the person has been cured. No person will be entered as cured until he has been found negative on careful microscopic re-examination following treatment. (14) Latrine Improvement. The heading "Latrine Im- provement" is divided into twelve columns, six under the sub-heading "First Inspection," and six under the sub-heading "Last Inspection." Of these six columns, four are for recording the types of latrines found, and the fifth and sixth for the date of the inspection. The headings of the four columns for recording the types of latrines are, respectively, D, E, F, and "Other." The significance of these headings is as follows: D indi- cates any type of latrine which prevents soil pollution and is fly-proof. This includes (i) the fly-proof pail latrine, where the ultimate disposal of the night soil is under careful supervision, and is satisfactory; (2) the pit latrine, when fly-proof and so located that the drink- ing-water supply is not endangered by pollution; (3) sep- tic tanks satisfactorily constructed; (4) sewerage; and (5) incineration plants. The E denotes any types of latrines which do not prevent soil pollution or which permit flies to have access to the excreta. This includes (i) all latrines built for privacy only; (2) pail latrines, where disposal is unsatisfactory and the latrines are not fly-proof; (3) pit latrines not fly-proof and located so as FORMS USED IN INTENSIVE WORK I3I to endanger the drinking-water supply; and (4) septic tanks improperly constructed or not kept in order. F indicates no latrine of any kind. The column headed "Other" is for recording any special types which may be of particular significance in the country or dis- trict where the inspection is made. Two inspections are provided for: first and last. The first inspection is made when the census of an area is taken. The last may be made at the close of the campaign or later, as determined by the medical director. A comparison of the results of the two inspections will indicate the latrine improvement resulting directly or indirectly from the campaign. In recording the results of a latrine survey under these heads, one latrine is recorded for each household. Where one large latrine serves several households, the type of this latrine is recorded as many times as there are house- holds using the latrine. Microscopic Report Sheet (Form 130) This sheet is for the use of the chief microscopist in recording the daily work of his department. By using the initial letter of each microscopist or a distinguishing number to indicate positive findings, the comparative efficiency of each microscopist is made evident. The headings of the first three columns on this form may need some explanation. In Column i, "House Number " indicates the number of the home in which the individual lives. In Column 2, "Patient's Number" is the number given the patient in the case-record book. In Column 3, "Examination Number" indicates whether the examination is the first, second, third, etc. 132 APPENDIX \ I _Lj u^awriM K asndmiNas I d z Q 111 631ISVUVd 1- UJ I Q q: u UJ a: 1I3H10 d z UJ □ BnvMOOM3J.6 •ASNOtii.S •OHOlMi saaroo WUOMMOOH y E V) Q 111 Z 1 < X III u t 111 < z Q. Ill u QL u U i 111 s. < z to iij U) b: 3 Z a 111 > iii u lU a: u < Q NOIJ.VNIMVX3 C.XN3IXVd asnoH ' 1 z > -1 j i < < < 1- z 1 id 0. z K C 1 < ^ a K - Z S 5 1 V- £l ' ~"^ J in 1 z £ Q Z u. F 1 u. S2 1 >- J c UJ < < 2 1- »- z < Z s D 2 U) TO 2 n <0 N 2 ^-v t<-> » ^^ ^^ £ X Im Hc< 00 iH e 4-1 k4 CO P^ u E a (4 3 u U (A (« u SI . -o 134 ' APPENDIX Treatment Book (Form 128) This book is for the use of the nurses in giving treat- ment in the field. In it are recorded the name of the area, the number of the nurse's district, the name of the nurse, and the house number, patient's number, name, age, and sex of every infected person in the nurse's dis- trict. Following each name, columns are provided for recording the dose of the anthelmintic, the date, and the result of re-examination following each treatment. It will be noted that the column for re-examinations first appears after second treatment, and then successively after each treatment. It has not been found necessary to examine the patients after the first treatment, since so few are cured by one treatment. Columns are pro- vided for eight treatments and seven re-examinations. These books should be of a size to accommodate 200 names, which is probably the maximum number of in- fected people that will be included in a nurse's district. Nurses' Reports: Daily, Weekly, and Summary (Forms 131, 132, and 129) The three following forms for nurses' reports are for administrative purposes only: 1. Nurses' Daily Report Sheet. In order to keep the medical director informed of the progress of the work and of the efficiency of the nurses, each nurse is required to make a daily report of the work accomplished in his district. Form 131 is for this purpose and provides for reporting the total number of patients under treatment, the number of first to eighth treatments given, and the number of specimens collected. The nurse's name, the district, and the date also form a part of each daily report. FORMS USED IN INTENSIVE WORK I35 2. Nurses' Weekly Report Sheet. This report is more elaborate than the daily report, as it shows the progress in each nurse's district by weeks, from the begin- ning to the close of the work. At the end of each week entries are made on this sheet showing the name of the nurse and the number of people found positive. Under the heading "Before Treatment" there are recorded the "Number not treated for medical reasons," "Number removed," "Number refusing treatment," "Number not located," and "Number died"; in eliminating these from the "Number positive," we have the "Total number available for treatment." Of those "Available for treat- ment," those "Given first treatment" appear in the proper column and also the "Total number of treatments" given. Under the heading "After Treatment" are columns for the "Number cured," the number "Discontinued treat- ment for medical reasons," "Number removed," "Num- ber refused," and "Number died." Three additional columns provide space for recording the "Number re- maining after first treatment," the "Number under treatment,'' and the "Number now available for treat- ment." A consideration of all of these facts at the end of each week shows the director, not only the prog- ress of the work, but its extent in the beginning in that particular district and its progress toward completion. 3. Nurses' Weekly Summary Report Sheet. Upon this sheet is summarized all information contained in the nurses' weekly reports. At a glance the Director can see the status of work in any nurse's district and judge of the efficiency of that nurse, and he can also sum up the situation for the entire area of operation. 136 APPENDIX DO 30 CTQ FORMS USED IN INTENSIVE WORK 137 «c,..«,„.„ h Z t- < 0: 1- K u 1- < 1- z u : t- < u E 1- I is is Ul < H Z 2 1- < 0: H I l- 10 is IS u < Q HC,X_.MJ«,X, 1- 2 2 1- < DO Q I- U < □ HC,.,^,^,.. 1- Z < Om DO tea a 5 u 1- < □ "-■^•-'"'X' Z u S 1- < h 4 ill Ou) DO aa a u < X! Uh vr> »N ^ c •t-i 7i c - -J CM < q: Ll 1 Q LI 5 5 t- U) < D Z o "" i Z 1 ' , ; T j 1 j i 1 1 q: E "5 D 3 1 Z z Q *-> c Q 3 -1 u ^ en iij lU K D Z ^ en D Z -1 v^ J ^ S J < s J -1 ^^ J < s J iij < u < u < u ooS 1-11.5 en 1-u.S 00< 00" f-L.5 oo< 00^ 00< ooy 00< 00< HKQ ►-I-D Fl-C h-t-Q l-l-Q q: a D \h Z Q Si FORMS USED IN INTENSIVE WORK r— 1 1 1 1' i 1; 1 , i 1 i TOTAU FOR WEEK TOTAL TO DATE < ^ 00- 00< ooS I-U.5 00< 00 = -1 < u I- H 00< l-l-Q 2?2 00< I-U.5 00< ei-Q 141 N c<^ -^ HH » E X •«« fc 00 ^ *j r; B a, (U ii P< en >. F j^ CO -— 142 APPENDIX UI >- o > O 111 ^^< U) K lu 3 K B. D h- Ul U ui 5 CI I- s in D a z FORMS USED IN INTENSIVE WORK 143 I I I " t I i j I I I J I I E k u h4 X tin Hn 00 l-i c E s E a 3 to c/o u >. E ^ (4 3 u iz; ^ TS t> 1 3 VO -0 4> Qi bJO i^ 144 APPENDIX The Diary (Form 48) The diary (Form 48) is intended to record information on educational work. It is designed to be small enough to be carried conveniently by the medical director. Each page provides space for recording the educational work of three days. At the top of the section for each day will be written the date, and the town, village, or locality visited by the medical director. The number of lectures delivered, the attendance at each, and the number of pieces of literature distributed, by classes, will then be inserted in the spaces provided. A sample page of the diary appears on page 145. Educational work may be roughly divided into two main classes: first, that by lectures; and second, that by literature. Lectures are of three kinds: public, to an audience of twenty or more persons not selected in any way; school, to an audience composed of school children; and special, to any group of persons belonging to a special class, such, for instance, as teachers, physicians, or mothers. Literature falls into four general classes: first, letters; second, pamphlets; third, leaflets; and fourth, notices or bulletins. The first includes all personal or circular letters written to any person in behalf of the work; the second, printed books or booklets more than four book pages in length; the third, the same class of printed matter as the second but less than four pages in length; while the fourth class includes notices or bulle- tins (placards) printed on a single sheet, giving notices of public meetings and other features connected with the work. Educational work in all of its phases is of course much more extensive than this, but it is believed that space has been provided for all of the features connected with this work which it is possible definitely to report. FORMS USED IN INTENSIVE WORK 145 FORM. 40 DATE PLACE LECTURES DELIVERED LITERATURE DISTRIBUTED | KIND NUMBER ATTENDANCE KINO NUMSER PUBLIC LETTERS SCHOOL PAMPHLETS SPECIAL LEAFLETS NOTICES ^BULLETINS TOTAL TOTAL REMARKS FORM 46 DATE PLACE LECTURES DELIVERED Literature Distributed | KIND NUMBER ATTENDANCE KIND NUMBER PUBLIC letters SCHOOL pamphlets SPECIAL LEAFLETS NOTICES aeULLETINS TOTAL total Remarks FORM 48 DATE PLACE LECTURES DELIVERED LITERATURE DISTRIBUTED j KIND NUMBER ATTENOANCe KINO NUMBER PUBLIC LETTERS SCHOOL PAMPHLETS SPECIAL LEAFLETS NOTICESa BULLETINS TOTAL TOTAL REMARKS Fig. 17. — Page of Diary, Form 48 (Reduced facsimile; actual measurement 4 x 61'.) 146 APPENDIX The records of educational work as kept In the diary are transferred at the close of the work in each area to the section headed "Educational Work" on Form 133. Geographical Area Report on Completed Work (Form 133) The geographical area report on completed work pro- vides space for all of the details usually reported upon in work by the intensive method. In it a complete sum- mary of the work in any geographical area may be given. It is not prepared until the work in the area has ended. These reports are furnished in duplicate, one for the government of the country where the work is in progress, and the other for the International Health Board. It is important that they cover the entire field of activities of the force, and at the same time be simple but intelligible, requiring the minimum of the director's time and atten- tion in their preparation. All of the information requested on this form is obtained from the case-record book (Form 100) except that for "Educational Work." Information on educational work is recorded in the diary (Form 48) and is obtained from it. It is believed that sufficient explanation of the headings on the geographical area report has already been given in the pages describing the case-record book and the diary. Quarterly Report on Completed Work (Form 50) This report is prepared and forwarded by the medical director at the end of each quarter. It is intended to show at a glance the results accomplished in geographical areas in which work has been completed during the quar- ter. The information it contains is taken entirely from the geographical area report. Two copies of the report are prepared, as in the case of Form 133, and one for- warded with the latter form to the government, the other to the International Health Board. forms used in intensive work i47 Quarterly Report on Work in Progress (Form 51) This report is also prepared and forvN^arded by the medical director at the end of each quarter. It is intended to show at a glance the results accomplished in geo- graphical areas in which the work has been in progress but has not been completed at the end of the quarter. It is identical with Form 50 in all respects except the heading. For Form 51 no supporting geographical area reports are desired. Two copies of the report are prepared as with Forms 133 and 50, one being forwarded to the govern- ment and the other to the International Health Board. Special Monthly Report for the Information OF Regional Directors The regional directors of territories in which intensive work is being conducted may wish to keep more inti- mately in touch with the progress of the work than can be done by means of the regular quarterly reports above described. This may be accomplished by having the medical director in charge of the work in each country mail monthly to the regional director a special report on a form similar to that shown on page 154. This will give information concerning the total results accomplished by the staff during the month, irrespective of the areas in which it was engaged, while, by showing the number of employes of each class, it will enable the regional director to measure progress and to apply pressure if satisfactory results are not being obtained in every department. Narrative Report Each quarterly statistical report is usually accompanied by a narrative report prepared by the medical director. 148 APPENDIX ° * H i * J s .t z s li < i □ 3 U 1- z 1- sp > < z T Z V) V)E 2a > Z Ill z 3 a s 1 _J I. iii > g > P £ 3 ,_ 2 ^" si°s 01 S 'xuj *^* " s ^ o z z : z 1 1: < < = « < z < a: < 1- Z > z Z z = 2< Zt- > z H »' I 2 1 s - > Z 5 < A > > i "^ |-z "*>< 0. t- < a 2 I^' sj^ Ss y 3£ < s;S z 2 J J tj z 0: z 1 (A Id 1- t- " 2 2 — i Q 3 > p < z H z > 5 1- 3 < \- 1 < a. t I i z 2H 5 z z 3 2 u. It a ;5, S i J" u — ^^~ u u ' u >5; Q < 5 z UJ > s: {L > p Z X < tEJ ■* i " ^K aui ° 3£5 ► S < < < < i J >- '2 g ° 5 -J *" ^ H > < »- n z z ui7 K s ;si 5 S 5 > « z Be 3 i z t a a».il > p > p 3 2 " ^•i 2 ^a ir> ?H5 S w 2o « " i'j 3 T »- ^ ^ i tt 1 q: J2 J -1 5 < I « S * E 5 1 1 z 5 > < 5 5 Ik M atinD QNV 'XN3HlV3ijl 'N0I1VNIWVX3 S3iisvyvd a3Hio 1 SNoiiVNiHvx3-aa S1N3N1V3III S3D¥a« N0I133J FORMS USED IN INTENSIVE WORK 149 lN3VllA0!l- ra 4-1 Q. Ui tt, 0. 0) " g 2 o 3 Z 5 i^ 2 1- o *J ^ z - 5 J u 1 z o o U) < 3 i * 2 z J 5 < > « 5 5 C I Z < < I a. < IT 2 FORMS USED IN INTENSIVE WORK 151 z >3 I 1! ^1 (1 < I >- n H *" II o 10 O X 13 '(-> 1> c *-i u ^ y 3 -a Pi c o 152 APPENDIX fO UJ tn a: < < DC < O Z Ul o z I => 7 u. o 2 -J Q o o Z o a UJ 1- z K Ui Ul o -1 o < z a D o z O o < u z b. bJ I »- UJ UJ m .J (C Ul C) z q: u. < H I (K y O a: la. O i^ 5 K o () $ X z $ o z h- q: U) O 0. (r bJ < 0£ -J >- < -1 u 0£ I bJ h- < tc < O 3 O UJ > S ° S 1 Si 3 z o J \ D 3 Z ; 2 •" 5 i' u j O 1- o 1 ; ° u i 3 £ z > S z 3 Z u < < o i a. < o 2 FORMS USED IN INTENSIVE WORK 153 1 c 1 a z i < •■ 2 > J > E ? ft. 2 I I J i5z 1 1 < * s i; 5 S * J ^ a » 1! < u < < u ! < 0: i "-> p u r-r ^^ C/0 CO »^ CJ ►^ X u 00 Oh jj c n 4J b J:«J i! Ui 3 M ^ E r. a *-> Ui G, .ak QJ P^S 154 APPENDIX MOCTHLY REPORT FOR THE I1JF0R1IA.TI0H OF THE RSGIOMAL DIRECTOR FOR THE , territory Report of the hookworm campaign in , for the month of name of country (1) Additions to census (2) Refused examination (3) Removed before examination (4) First examinations made (5) Re-examinations (3) Total microscopic examinations (7) First treatments given (8) Treatments refused (9) Removed before cured ( 10 ) Total treatments (11) Cured (12). Expenditures for month: Medical director, salary and traveling expenses Rest .of staff (13) number of micropists' employed (14) Number of nurses employed (IB) Remarks ____^___________ (Sigijed) Uedioal Director Fig. 21. — Special Monthly Report For Information of Regional Directors (Reduced facsimile; actual measurement, 8| x 1 1 *) FORMS USED IN INTENSIVE WORK 1 55 When a new area of operation is entered, this narrative report deals with the population, its nature and distri- bution, living conditions, topography of the area, and a general description of the conditions to be met. Narrative reports on areas where work is in progress may be brief, setting forth interesting features which have developed and the progress made in the area. The narrative report of a completed area is expected to combine all information given in previous narrative reports regarding this area, and to give a final summing up of results and the local conditions which have favored or hindered the work. In addition, this report may mention the general conditions responsible, in the begin- ning, for the presence and spread of hookworm disease, and the measures taken to remedy these conditions. The annual narrative report obviously should deal with the work and experiences of the entire year and is more or less a combination of all narrative reports for the year. Budget (Form 12) Each budget is a detailed statement of the funds re- quired for work in a country or a state, or by a definite unit of working force during a fixed period of time. A typical annual budget for a standard unit of working force where work is done by the intensive plan is shown on pages 156-157. Where there are several units of force operating in a state or country, each has its own budget. Each budget bears in its upper right-hand corner a serial number by which it is known, and each item for which the expenditure is fixed is given an independent item- number. After being duly approved and signed by the proper authority, the total expenditure authorized by a budget, or the amount set apart for any of its numbered items, cannot be changed, or the funds under one item 156 APPENDIX to '-t z o> JLl f-t P l-_l l-t J Tf to CD 1 CO rH rH U Oi 1 CD oo o o C30 OW in ># oo oo OC3 COO ■>* 03 . o H • • • z C t-« O 1 O o +» +» q: n 4* •P p < rH 05 u fc • a a • O C r-t SS E^ a •H < 0) O f-t o O +» P. ° D 4) >k M » <0 o • z . >^ +3 ^ Q o •H o 3 JJ o C CtJ .J ■•-> 4) 0) m (0 K l-H 3 U o OJ4 to 05 o+* £5 >» C 1 n (D ^< M ->J +» M cJ M "Vl C3 &^ M O V Q> O (d q: S -iJ o •-3 ■H fa rH rH •H -H 43 U Hi C O O BJ o,a 00 -1 z d 60 1- rH O O -'H ^1 o B u r-t nJVt-H 0 01 +> 3 n f>l TJ Q>00 oo to O a o u 1 td o r-f ■<-{ ^ V V fj s o s a: to ■a o a Oi 0} a u > W bj (0 :2i u N o Z c H z 1- 3 < o a a. z r-< 03 to FORMS USED IN INTENSIVE WORK 157 158 APPENDIX be applied to expenses under another, except by the authorization and issuance of a new budget embodying the necessary modifications and bearing another serial number. As a separate account is kept of the expendi- tures under each numbered item, in arranging supersed- ing budgets it is essential not to disturb the previously assigned item-numbers, as this would lead to confusion of accounts. In the experience of the International Health Board in the foreign field it has been found that items such as drugs, scientific instruments, etc., in certain cases may be purchased more advantageously in the United States than either locally or in European markets. In such cases funds to pay for these items are held in the Home Ofl&ce to avoid double charges for exchange, and such amounts are designated "Home Office Funds." All budgetary funds which are to be expended in the country where work is in progress, such as salaries, rent, office furniture, etc., are known as "Field Office Funds.'* Budgets are usually arranged to provide funds for a definite working force operating during a calendar year. In certain cases they are made for a shorter time, but they never overlap from one calendar year to another. At the end of a calendar year all unexpended budgetary funds automatically revert to the source of such funds, which in our work in the West Indies is the Interna- tional Health Board, only becoming available for ex- penditure by official action appropriating them to the needs of a new budget. Explanatory Notes on Budget 1. Salaries. The salary and traveling allowance of the medical director (item i) are not included in the budget, as these are subject to wide variations accord- FORMS USED IN INTENSIVE WORK 1 59 ing to the country where such work is undertaken and the grade of service from which the medical director is secured. No traveling allowance is made to any mem- ber of the force except the medical director. The maximum salary of chief clerks in the West Indies {item 2) is placed at $50.00 per month. As a rule they may be employed for less. The assistant clerk is never paid more than $35.00 per month. The maximum salary of the chief microscopists {item 3) has been fixed at $40.00 per month; the assistant microscopists receive from $25.00 to $35.00 per month. The maximum salary of the chief nurse {item 4) is $40.00 per month. The nurses are paid from $25.00 to $35.00 per month. The annual estimate of $4,200, or $350.00 per month, for the item of assistant nurses in the sample budget, is based on the following arrangement of salaries: Per month Per year 6 Nurses at ^25.00 per month ^150.00 ^1800.00 3 " " 30.00 " " 90.00 1080.00 3 " " 35.00 " " 105.00 1260.00 The additional $5.00 per month is for bonuses for the nurses showing the highest efficiency in their work. The caretaker {item 5) is usually a woman who lives near the laboratory office and who may be employed for a comparatively small salary. 2. Office Equipment. The equipment {item 6) con- sists of the following items: (i) Office and laboratory furniture, including tables, one type- writer, chairs, lockers, file cases, bowls, buckets, towels, etc. (2) Stationery, envelopes, etc. (3) Rents, light, and water supply in office and laboratory. (4) Printing of record books, forms, literature, etc. l60 APPENDIX 3. Scientific Equipment. This equipment for one unit of force {item i8) consists of the following items: 1 Microscope, portable, equipped with triple revolving nose- piece; objectives i6, 4, and 1.9 m.m.; Abbe condenser, screw sub-stage. (Cat. No. APS-8.) 3 Microscopes, portable, equipped with double revolving nose- piece; objectives 16 and 4 m.m.; two eye-pieces, 5 and loX. (Cat. No. APS-4.) 4 Mechanical stages to fit above microscopes and adapted to use of 2 X 3" slides. 2,000 Microscope slides, 2x3*. 2 Special double-speed hand centrifuges with Stewart panheads. 600 Special tubes for Stewart panheads. 112,500 Corks for centrifuge tubes. 300 Funnels to fit centrifuge tubes. - 1,600 Flat-bottom vials. 250,000 Flat wooden toothpicks. 6 Talquist hemoglobin index books. I Balopticon, with accessories consisting of 2 Prest-0-Lite gas tanks, I screen, i standard set lantern slides, 2 hookworm charts. I Camera, with accessories, as follows: I Leather carrying-case, i tripod, 2 dozen 6-exposure film rolls in tin. 450 Gross containers.^ 4. Drugs. The amount allowed for drugs {item 19) is based upon the supposition that one unit of force will handle a population of 15,000 people annually, where there is an average rate of infection of 65 per cent. This would mean that in a year the one unit of force would need to treat approximately 9,750 infected people. The average amount of thymol necessary to cure an adult case is 120 grains. This would be administered in cap- sules which contain 10 grains of finely powdered thymol combined with approximately an equal quantity of milk ^ Experience shows that with an average infection of 65 per cent, 30 gross of tin specimen containers are required for each one thousand of population. For a population of 15,000, 450 gross would be required, which at the present price of 75 cents per gross would cost approx- imately $337.50. FORMS USED IN INTENSIVE WORK l6l sugar. Twelve of these capsules would be required as an average to each case. About one-fifth of the cases found infected are usually children who require only one-half the adult dose of thymol, or 60 grains. For use with children, the thymol is put up in gelatin capsules also, each containing 5 grains of powdered thymol and an equal quantity of milk sugar.^ An average of twelve capsules is required for each case treated. The prices for these capsules are very high at present and are subject to change owing to the decrease in the production of thymol because of the war, thymol having advanced 300 per cent in the last two years. The following table shows in detail the annual estimate for thymol for one unit of force: To be treated Thymol capsules required Cost Children 1,950 23,400 5 grain $300.83 Adults 7,800 93,600 10 grain $2,481.52 Total 9,750 117,000 $2,782.35 Sulphate of magnesia has seemed to serve best as the agent to be used in clearing out the alimentary canal, both before and after the administration of thymol. It is estimated that each adult case treated will require two-thirds of a pound of magnesium sulphate, and each child one-half pound. At present this salt in bulk, packed in kegs of 125 pounds each for ocean transportation, is costing approximately 4I cents per pound. The follow- ing table shows in detail the annual estimate for mag- nesium sulphate for one unit of force: To be treated Magnesium sulphate required Cost Children 1,950 975 pounds $43.88 Adults 7,800 5,200 " $234.00 Total 9,750 6,175 " $277.88 ^ The powder is taken out of the capsule and administered with water or in syrup in cases of children too small to swallow the capsule. l62 APPENDIX HO §0?: 2-10: Ojo <1L m Ul ^ 6 2 LI z K 111 5 z u o O 0. X i s Ul o 2 < •9 Z 0. iZ ij o u a z H z O^ ^ i° s D >- 01 s * u. > >- 111 ir O K (L z S 3 O a. s i E u < a o i 3 Ul > ul K 5^ C a O a a u m o z - u < u c -1 u cc ® 111 < X > Q e w u X S o Q c u UI.Ul 3-3 b a a z FORMS USED IN INTENSIVE WORK 163 ""it- M fi s X Im 00 tXH c ^ 4> *■> H b a. 3 (U r« P6^ n rt 3 r, U CJ c .« u tL^ b ca u t*^ <2 r< •o a> (J hf 3 -0 U, 164 APPENDIX The estimated cost of thymol capsules and magnesium sulphate thus amounts to approximately ^3,000 annually for each unit of force. 5. Contingent Fund. The contingent fund (items 7 and 20) is intended to meet emergency expenses not otherwise provided for in the budget, such as freight, cartage, postage, etc. A part of the contingent fund is usually allotted to "Field Office Funds" and the re- mainder to "Home Office Funds." Note should be made of the fact that a large part of the expenditure under 6 and 18, is for permanent office and scientific equipment. A force once fully equipped will require subsequently but a very small outlay for minor supplies under these heads. Quarterly and Yearly Financial Reports (Form 24) The financial report form shown on pages 162 and 163 has been prepared for use by Medical Directors in the field in reporting receipts and expenditures. This form is so worded as to be adapted to a report covering a year or any other period. In making out the financial reports care should be taken to observe the following: (i) After "For" at the top of the form put the name of the country, area, or other description. Copy the exact words used in this place on the Budget. (2) Under "Receipts during Period" describe accu- rately the checks, drafts, letters of credit, and other forms of remittance. Ill LIST OF STANDARDIZED SUPPLIES AND PRICES Since the outbreak of the Great War it has become very difficult for medical directors to buy and secure prompt delivery of supplies of any nature directly from the manufacturers. This has led the International Health Board to offer its services to the medical directors in various countries to place orders for supplies and expedite the shipment of these as much as possible. No charge is made for this service. The following is a list of supplies for which the International Health Board is prepared to place orders. The prices given are approximate only and subject to change: APS-8 Portable Microscope, equipped with triple revolving nose-piece; objectives i6, 4 and 1.9 m.m.; two eye-pieces 5 and loX; Abbe condenser in quick acting screw sub-stage. Price $72.50 each. APS-4 Portable Microscope, equipped with double revolving nose- piece; objectives 16 and 4 m.m.; and two eye-pieces 5 and loX. Price, $40.50 each. No. 2 1 16 Mechanical Stages for above microscopes. Price, $16.00 each. 2x3" Microscope Slides (500 per microscope). Price, $2.25 per 100. Talquist Hemoglobin Scale Books. Price, $1.75 each. No. 19002 Double-speed hand Centrifuge without sedimentation attach- ment, hematokrit, or accessories of any kind, with separate clamp. Price, $5.50 each. Stewart panheads for double-speed hand Centrifuges, equipped with nut for fastening on centrifuge, and without milk tubes, rubber corks, and nipples regularly supplied. Price, $9.00 each. Special Tubes for Stewart panhead, heavy wall. Price, $1.50 per 100. Corks for Tubes, No. O, XXXX quality. Price, $.20 per 100. i6s l66 APPENDIX Glass Funnels, 40 m.m., to fit special tubes. Price, $18.00 per lOO. Vials, flat-bottom, 25 m.m. high, 15 m.m. diameter. Price, $1.00 per 100. Prest-O-Lite Gas Tanks, 10 cubic feet. Price, $10.00 each. Model "C" Balopticon, with acetylene burner. Price, $52.20 each. Tin Containers {\ ounce). Price, $0.75 per gross. Cases of Toothpicks, each containing 180,000. Price, $2.50 per case. Standard Set of Lantern Slides, containing 47 slides numbered I to 55 inclusive, excepting Nos. 31, 43, 44, 46, 47, 48, 49 and 54. Price, $.27! each. Lantern Slide Carrying Case, Style "C," detachable cover, Cat. No. 3660, for 80 slides. Price, $2.25 each. 3-A Autographic Kodak, with Kodak Anastigmat Lens, f. 7.7, and Au- tomatic shutter. Price, $32.50. Black Sole Leather Case with strap. Price, $2.00 each. Films for Camera, 6-exposures, in sealed tins. Price, $.40 per roll. Hookworm chart, International Health Board, Price, $5.00 each. Thymol, in bulk, crystalline, in 25-pound tins. Price, $16.00 per pound. Cost of capsulating Thymol: Thymol, 10 grains; sugar of milk, 8 grains, $3.20 per 1,000 Thymol, 5 grains; sugar of milk, 5 grains, $1.20 Thymol, 2^ grains; sugar of milk, 23 grains, $.90 Allowing 2% for waste, 1,000 25 grain capsules require .3642 pounds Thymol, 1,000 s " " " .7285 " 1,000 10 " " " I.4S7 (The pounds used here are avoirdupois) Magnesium Sulphate, in kegs of 125 pounds each. Price, $.04^ per pound. Oil of Chenopodium, in bulk, packed in i-gallon jacketed tins. Price, $60.00 per gallon. Oil of Chenopodium, 10 minim flexible capsules (not recommended). Price, $26.10 per 1,000. Oil of Chenopodium, 5 minim flexible capsules (not recommended). Price, $14.60 per 1,000. LIST OF STANDARDIZED SUPPLIES AND PRICES 167 Capsules required for 1 gal. Chenopodium I Gal. = 61440 minims U.S. Apoth. Fluid Measure Quantity Chenopodium * Gal. chenopodium requires Contents capsules capsules No. capsules 000 16 minims each 3840 00 14 minims ' 4389 9 minims ' 6827 I 7 minims ' 8778 2 5 minims ' 12288 3 4 minims ' 15358 4 3 minims * ' 20480 S 2 minims ' * 30720 for imp effect capsule s. These often amount to as much as 10%. Apparent Age of Patient ^ I to S years 6 to lO " 11 to IS " i6 to 20 " 21 to SO " Over SO " IV DOSAGE TABLE lYMOL AND Solution Magnesium Sulphate 1 Dose of Thymol Dose of Magnesium Sulphate Solution 3 to s grains 10 to IS " IS to 30 " 30 to 4S " 45 to 60 " 30 to 4S " 2 drachms 4 6 8 12 " 12 " The magnesium sulphate solution is prepared by dis- solving 15 pounds of the salts in 3 gallons of boiling water. This gives approximately a 2 to i solution, i.e., 2 drachms contain in solution i drachm of magnesium sulphate. ^ In arranging dosage by "Apparent age of patient," it is intended that the age in years should not be the only factor, but that due con- sideration should be given to the robustness, development, and size of the patient. 168 V GENERAL INSTRUCTIONS FOR NURSES The nurse must discontinue treating persons who de- velop the following conditions during the course of treatment, and must not resume their treatment until directed to do so by the medical director: (i) Very old and feeble persons who are markedly de- pressed by the treatment. (2) Children under five years of age who are made ill by the treatment. (3) Persons who develop acute malaria, dysentery, diarrhea, rheumatism, or fevers. (4) Pregnant women. These should never be treated outside of hospital. (5) Persons who develop dropsical swelling of face or lower limbs. Before treating a person showing signs of ill health, the nurse should make inquiries to ascertain if any of the following conditions exist: (i) Swelling or dropsy of the feet and ankles, or face; or bloody urine and suppression of urine. These are often indications of kidney affections which contraindi- cate the administration of both thymol and chenopodium. (2) A recent attack of dysentery or diarrhea, or the existence of either of these in chronic form. (3) Recent acute malarial attack. Often the giving of magnesium sulphate will precipitate a severe malarial chill where a chronic malarial infection exists, and if this occurs in giving the treatment for hookworm disease the treatment is held responsible for the illness which results. 169 170 APPENDIX (4) Extreme shortness of breath on sHght exertion, pulsation of the veins in the neck, or extreme palpitation and irregularity in the heart's action, with cough. These symptoms may indicate a dangerous organic heart lesion which would make the treatment for hookworm disease unsafe. (5) A chronic cough, with loss of flesh, and evening fevers and sweat. It is not safe to give treatment to well- developed cases of pulmonary tuberculosis except in hospitals. (6) In female patients between the ages of 15 and 45 the possibility of an unsuspected pregnancy should be investigated before treatment is administered. Directions to Nurses for Administering Treatments (i) A dose of magnesium sulphate (see Dosage Table) is given on the night before the thymol is to be adminis- tered. With the more intelligent classes of people the dose of salts may be left to be taken at bed time. The patient should be advised to refrain from eating supper, or in any event to eat only a light meal, avoiding greasy foods. (2) No breakfast is to be eaten by the patient the following morning. At the time agreed upon the nurse is to call on the patient and ascertain if the dose of salts given the night before has thoroughly cleared out the alimentary canal and if the patient has refrained from food as directed. If these conditions are found favor- able, the nurse administers the first dose of thymol, and in two hours the second dose. (3) Two hours after the second dose of thymol is given the nurse administers a dose of magnesium sulphate. GENERAL INSTRUCTIONS FOR NURSES I7I Both doses of thymol and the dose of magnesium sulphate which follows them should always be given by the nurse, who must assure himself, before leaving the vicinity of his patient, that the last dose of salts has acted thoroughly and has cleared away the dead worms and the thymol from the alimentary canal. (4) While the nurse is administering treatment at other nearby homes, the patient should be instructed to summon the nurse if any untoward symptoms develop, and to notify him if the dose of salts does not act within two hours after it is given, in which case the dose is to be repeated. VI CONTRACT WITH SUBORDINATE EMPLOYES I, the undersigned, accept employment with the Ankylostomiasis Commission at a monthly salary agreed upon between the medical di- rector and myself in the presence of witnesses, under the following terms and conditions: First, the services which I am to perform will be under the medical director of the Anky- lostomiasis Commission and consist of any duties he may assign to me. Second, I am employed on the condition that I shall be able to perform to the satisfaction of the medical di- rector the duties assigned to me, exercising at all times due diligence and faithfulness to duty in all services re- quired of me. Third, in case I am not able to accomplish such duties as are assigned to me to the satisfaction of the medical director, or am insubordinate, or for other just cause am dismissed, I agree to accept two weeks as sufficient notice of my dismissal from the service of the Ankylostomiasis Commission, and to waive all claims to a longer term of notice of dismissal or to salary for any time beyond the two weeks for which this notice is given. Fourth, I agree that misconduct and absence from work, unexcused by the medical director, will entail a deduc- tion from my monthly salary. Fifth, I further agree that in case I resign from the employ of the Ankylostomiasis 172 CONTRACT WITH SUBORDINATE EMPLOYES I73 Commission I shall give the medical director two weeks' notice of my resignation from the service. Signed Title of Employe Note: In case of nurses a sixth clause is added: Sixth, I further agree to provide myself with a bicycle or such other means of travel as may be required of me by the medical director of the Anky- lostomiasis Commission, and to maintain the same at my own expense throughout my term of service as nurse in the force of the Ankylostomiasis Commission. VII SAMPLE CIRCULAR USED IN BRITISH GUIANA HOOKWORM DISEASE YOU MAY BE TREATED AND CURED FREE OF COST The International Health Board, working with the G)lonial Government, will give FREE examination and FREE treatment for HOOKWORM DISEASE to every man, woman, and child. In each district will be established a FREE DISPENSARY with a force of skilled men to examine the people, and a PHYSICIAN in charge who has had wide experience in the treatment of this disease. Many thousands have al- ready been examined and treated on the ElAST and WEST BANKS and on the EAST COAST from KITTY to BUXTON inclusive. As a result the people in these areas are much stronger and healthier than before. Now this great boon is offered to you for the first time FREE OF COST. Investigations al- ready made show that about six out of every ten of the people in the villages have this disease, and many of these people are SICK AND WEAK on ac- count of it. Many of the ailments of which people complain are due to the presence of the HOOKWORM in the body, where they may exist in HUNDREDS and where they BITE THE INTESTINES and SUCK THE BLOOD, thus sap- ping the strength and vitality of their victims. The symptoms of the disease are many. Some, but NOT all of them, are as follows: — HEADACHE, DIZZINESS, INDIGESTION AND DYSPEPSIA, PALPITATION OF THE HEART. KIDNEY TROUBLE, DROPSY, PALENESS, SHORTNESS OF BREATH — which may be so severe as to be called ASTHMA — CONSTI- PATION, WEAKNESS, and STOPPING OF PHYSICAL AND MENTAL GROWTH and DEVELOPMENT. Often the symptoms are so mild for a long time that the victim does NOT SUSPECT THE PRESENCE OF THE DISEASE UNTIL GREAT HARM HAS BEEN DONE. Therefore, no one can consider himself safe until an EXAMINATION WITH THE MICRO- SCOPE shows him to be free. We often find people who think they are in good health until our examination shows that they are infected. The HOOKWORM lives in the small intestine and FEEDS ON THE BLOOD. The female lays hundreds of eggs every day. These never hatch in the body, but must be passed out in the bowel movements and deposited on the ground or they do not hatch. Those which are deposited on the ground hatch into worms too small to be seen. These worms live in the soil wherever the ground is contaminated. From the soil they usually get upon the feet and pass through the skin in a few minutes, and then into the blood, and after a few days they have found their way into the small intestine, where they live for 174 SAMPLE CIRCULAR USED IN BRITISH GUIANA 1 75 years if not treated. When they pass through the skin they cause sores which itch and fester, and which are commonly called GROUND ITCH when occur- ring on the feet. So it may be said that ANYONE WHO HAS HAD GROUND ITCH HAS HOOKWORM DISEASE. However. ONE WHO HAS NOT HAD GROUND ITCH MAY HAVE HOOKWORM DISEASE. This is true because in some cases the worm GETS IN THROUGH THE MOUTH ON VEGE- TABLES AND FRUITS WHICH ARE NOT COOKED BEFORE BEING EATEN. THE WORMS AT THIS STAGE ARE SO SMALL THAT THE MOST CAREFUL WASHING MAY NOT REMOVE THEM. On this account no one will be safe from the disease under present sanitary conditions. SOME OF THE RICHEST AND MOST INFLUENTIAL PEOPLE IN DISTRICTS WHERE WE HAVE WORKED BEFORE. HAVE HAD THE DISEASE. The EIXAMINATION, which is necessary, consists in having each individual, from the youngest to the oldest, furnish us with a small bit of bowel movement, and with this his NAME, AGE, ADDRESS, and RACE, for purpKJses of identification and record. This specimen of bowel movement is examined by an expert at the Dispensary, and if HOOKWORM EGGS are found we know that the person is infected, and treatment is given. Our men will call at your homes and give you small boxes to collect the specimens in, and will also deliver the medicine to you there so you can take it without in- convenience. The treatment is not severe and the cure is certain and speedy to all those who faithfully take treatment regularly, and to all who are cured is issued a certificate of health. The above examination also enables us to determine if the person examined has any other worm or parasite. The OB- JECT of our work is to ERADICATE this disease entirely, and show the people how to protect themselves from it in the future. To do this it will be necessary to EXAMINE EVERY PERSON in the territory where we are working. It is plain to any one that we would fail to stop the progress of this disease if any cases were left untreated, for it is an infectious disease, and every case originates from some other case. In view of this fact it would seem to be the duty of every official — every intelligent, progressive citizen — not only to have himself and his entire house- hold examined, but also to use his influence with his friends and acquaintances to secure their co-operation in this work. Already more than A MILLION people have been treated in the United States by taking advantage of the same offer which is being made to you. If you are free from the disease you should want to know it. If you have the disease you should be treated and cured, for it is a serious malady often resulting in DEIATH, either directly or indirectly, and no person who has it can ever hope to be as useful, happy, or prosperous as he would otherwise be. Talk this matter over with your friends and neighbours, and help us to help you. You are cordially invited to attend the lectures which will be given on this and other diseases from time to time, of which you will have further notice; and also to call at our DISPENSARY and see the work actually in progress. VIII DESCRIPTION OF SPECIAL CENTRIFUGE No. 19002 Double-Speed Hand Centrifuge with separ- ate clamp, equipped with Stewart panhead with nut for fastening to centrifuge shaft. Accessories: (1) Special glass tubes, heavy wall, open at both ends to fit clips ol Stewart panhead. (2) Glass funnels, 40 m.m., or special paper funnels. (3) Vials, flat bottom, 25 m.m. high, 15 m.m. in diameter. (4) Corks for Centrifuge Tubes, No. O, XXXX quality. Fig. 24. — Special cen- trifuge used in exam- ining specimens. {Left) Shaft, showing manner of clamping to table. {Right, above) Stewart panhead with specimen tubes in position. INDEX PAGE Alcohol, Solubility of Thymol in .- 79 Also 69,73,76,83 Allowances, see Salaries American Journal of Otology, quoted 93 American Journal oj Physiology, quoted 90 Ankylostoma, see Hookworm Ankylostomiasis, see Hookworm Disease Anthelmintics 16 See also Oil of Chenopodium; Thymol Antigua: Table showing per capita cost of hookworm campaign loi— 102 Results of treatment, with table giving percentage remaining uncured 121-122 Also 58 Atropine: In thymol poisoning, with dosage 83 Aural Phenomena in Poisoning, see Oil of Chenopodium Aural Phenomena of Chenopodium Poisoning, by Dr. Samuel Seiton, quoted 93 Balopticon, see Supplies Barbados 58 Bausch and Lome Optical Co., Rochester, N. Y 64 Bicycle 52 Biggs, Dr. Hermann M.: Member International Health Board 5 Bismuth, see Milk of Bismuth Blanks and Forms Used in Intensive Method, see Case Record Book; Census Book; Reports; Treatment Book Branch Offices, see Working Staff Brazil 90 British Guiana: Use of iron sulphate in soil pollution 18 Hookworm control begun 21-22 Choice of Peter's Hall district 22 177 178 INDEX PAGE British Guiana — continued Local conditions and elements of population 22-24, ^^3 Changes in plan of operation 2$ Quarterly average of persons examined, treated, and cured 27-28 Technique of examinations, with comparison of methods S7~S8 Methods and results of treatment with thymol 69-71 Table showing per capita cost of hookworm campaign loi Dr. F. E. Field's report, quoted 108 Results of treatment, with table giving percentage remaining uncured 121-122 Sample circular used in hookworm campaign 174-175 Also 58, 78 Budget, see Reports BuTTRicK, Wallace: Member International Health Board , S Camera Films, see Supplies Capsules: Preparation 88-89 Cost of capsulating thymol 166 Number required for one gallon of chenopodium 167 Also i6o-i6i Cardiac Symptoms in Poisoning, see Oil of Chenopodium Caretakers, see Working Staff Case, Black Sole Leather, see Supplies Case Record Book: Description and use, with sample page 126-13 1 Castor Oil: In thymol poisoning 83 In treatment with chenopodium 84, 85, 86, 90, 91, 93-94 Cayman Islands 58 Census, see Nurses Census Book: Description and use, with sample pages 123-126 Also 46 Centrifuging: Description of machine used 64, 176 Table showing positive findings in Trinidad 64 Method of preparing specimens for examination 64-67 Importance in re-examination 67-68 Number of specimens handled daily 68 Also 58, 61, 63 See also Laboratory Technique; Supplies INDEX 179 PACE Ceylon 90 Chemicals, see Sulphate of Iron Chenopodium, see Oil of Chenopodium Cheyne-Stokes Breathing, in Poisoning, see Thymol Chief Clerk, see Working Staff Chief Microscopist, see Microscopists Children: Dosage of thymol 69, 161 Dosage of chenopodium 84 Also 169 Chinese, in West Indies 24* io3 Chloroform 84 Circular on Hookworm Disease Used in British Guiana. . . 174-175 Clerical Force, see Working Staff CoLWELL, Dr. H. S 88 Containers, Specimen, see Feces, Examination of; Supplies Contingent Fund, see Budget, under Reports Contract with Subordinate Employes 40, 172-173 Cost Figuring, see Treatment, Per Capita Cost of Creole Population, in West Indies 103 Demerara River, British Guiana 22 Diary, see Reports Digitalin: In thymol poisoning, with dosage 83 In chenopodium poisoning 94 Direct Smear Method, see Laboratory Technique Director, see Medical Director Dispensaries 38 Districts, see Nurses Dock and Bass: Technique of examination followed in British Guiana 57 Drugs i3» 4^ See also Budget, under Reports; Names of Drugs Dutch Guiana: Javanese among population 24 Table showing per capita cost of hookworm campaign loi Results of treatment, with table giving percentage remaining uncured 121-122 Also 58 East Indian Population, in West Indies 23, 24, 44, 103 Educational Work, see Lectures; Literature l8o INDEX PAGE Egypt 90 Embree, Edwin R. Secretary International Health Board 5 Employes, Contract with Subordinate 40, 172-173 Epsom Salts, in Thymol Poisoning 83 Equipment, see Budget, under Reports; Supplies Examination, Methods of, see Laboratory Technique Fats and Oils, Solubility of Thymol in 79 Feces, Examination of: Various techniques S5~S7 Method of preparing specimens 59 Also 3S. 44. 45-46, 48, S3, 54, S^^ also Centrifuging; Laboratory Technique Ferguson, Dr. J. E. A 22, 69 Ferrell, Dr. John A.: Director for the United States 5 Field, Dr. F. E., quoted 108 Also note 57, 78 Films, Camera, see Supplies Flexner, Dr. Simon: Member International Health Board 5 Forms Used in Intensive Method, see Case Record Book; Census Book; Reports; Treatment Book Funnels, see Supplies Gastro-intestinal Symptoms of Poisoning, see Oil of Cheno- podium; Thymol Gates, Frederick T.: Member International Health Board 5 Geographical Area Report on Completed Work, see Reports Georgetown, British Guiana 22 GoRGAS, Gen. William C: Member International Health Board 5 Grenada: Interval between treatment and re-examination 88 Table showing per capita cost of hookworm campaign lOl Results of treatment, with table giving percentage remaining uncured 121-122 Also 58 Heiser, Dr. Victor G.: Director for the East 5 INDEX 151 Hookworm: page Stages of life-cycle I3~I4 Chemicals and fire in destruction of larvae in soil 17-18 Also SO See also Soil Pollution Hookworm Chart, see Supplies Hookworm Disease: Distribution and control 13 Theory of prevention 14 Problem of eradication I4~IS Presentation of story under intensive method 3 1-32 Basis of diagnosis 55 Persons medically unfit for treatment 72, 169-170 Also 16 Hookworm Disease, Relief and Control: Necessity of microscopic examination 15 Co-operation of patients IS"!^ Installation and use of sanitary conveniences 16-17 Danger of re-infection 17 Soil pollution and prevention 95 Method of reckoning cost of campaign in West Indies 99-100 See also Intensive Method in Hookworm Control; Soil Pollution Hookworm Disease, by Dock and Bass 57 Howard, Dr. H. H. Director for the West Indies 5 Intensive Method in Hookworm Control: Definition and plan of operation 20-2 1 Publicity work 21, 33-35 Begun in British Guiana 21-22 Size and composition of working staff, with time required for completion of campaign in given area 26, 28-29, 37~39 Selection of area 26-27 Campaigns preceded by surveys 27 Educational aspects and purposes 3i~3S> 104-105 Work of nurses 3S~36 Required treatments 46-47 General applicability 103-104 Co-operation of population 105 Consideration shown to patients 105-106 Blanks and forms 123 See also British Guiana; Lectures; Literature; Medical Director; Microscopists; Nurses; Trinidad; Working Staff l82 INDEX PAGE International Health Board: Officers, Members, and Administrative Staff S Co-operative efforts with states and countries 18-19 Intensive method in hookworm control 20 Work in British Guiana 21-23 Offers services for purchase and shipment of supplies to foreign countries, with list of same 165-167 Also 56, 95. 96 Iron Sulphate, see Sulphate of Iron Javanese, in Dutch Guiana 24 'Journal of American Medical Association, quoted 86-87 Kodak, see Supplies Laboratory: Relation to curative work 55 Force and technique in West Indies 56 Also 35. 39. 44 See also Supplies Laboratory Technique: Based on work of Dock and Bass 57 Comparison of direct smear and present method S7~S8 Success in development 58-59 Recording and arrangement of specimens 59 Preparation of smears and work of examination 60-61 Advantages of direct smear method 61-62 Modifications 62-63 Number of smears necessary for examination 63 Table showing average number of positive findings 63-64 Number of specimens handled daily 68 See also Centrifuging; Feces, Examination of; Micros- COPISTS Lantern Slide Carrying Case, see Supplies Lantern Slides, see Lectures; Supplies Latrines: Installation in hands of local government 19 Phase of educational work 33 Noted in census report 53 House-to-house survey 9S~96 Types 96-98 Record of improvement in case record book 126-127, 130-13 1 Classification in census book 123 See also Soil Pollution INDEX 183 Leather Case, see Supplies pace Lectures: In opening campaign 31, 33-35 By Medical Director, to new nurses 50 Recorded in diary 144 Literature, Distribution of 34-3S> 144 Magnesium Sulphate, see Sulphate of Magnesia Medical Director: Management of working stafF 37~40 Relation to government 40-41 Relation to people 4i~42 See also Working Staff Methods of Examination, see Laboratory Technique Meyer, Ernst C: Director of Surveys and Exhibits 5 Microscopes, see Supplies Microscopic Laboratory, see Laboratory Microscopic Report Sheets, see Reports Microscopic Technique, see Laboratory Technique Microscopists: Duties of chief microscopist 43~44 Duties 44 Selection and training 44~4S Salary 51 Work in standard technique 60-63 Milk of Bismuth, in Treatment for Gastric Irritation. . . 81 Milk Sugar, see Sugar of Milk Minim, Unit of Measure 88, 89 Morphia: Use in thymol poisoning, with dosage 83 Murphy, Starr J.: Member International Health Board S Nausea in Poisoning, see Thymol Neuro-toxic Symptoms of Poisoning, see Oil of Cheno- PODIUM Nicaragua 9° Night Soil, see Soil Pollution Nitroglycerine: In thymol poisoning, with dosage 83 Non-treatable Cases 16, 72, 169-170 184 INDEX Nurses: ''*°'' Consolidation of districts 29-30 Publicity work 35-36 Care of treatment-books, supplies, and records 42-43 In charge of district 45 Census taking 45-47. 53-54 Treatment of infected persons 46-47 Duties of chief nurse 47-48 Selection and qualifications 48-49 Training in administration of drugs 49-50 Salary 51 Instructions regarding non-treatable cases 169-171 Directions for administering treatments 170-171 See also Case Record Book; Census Book; Diary, under Reports; Non-treatable Cases; Reports; Treatment Book; Working Staff Nurses' Report Sheets, see Reports Office Equipment, see Budget, under Reports Oil of Chenopodium: Results of use in West Indies 84 SchufFner and Vervoort method of treatment 84 Weiss method of treatment 85, 91 Recommendations by Uncinariasis Commission to Orient on routine of treatment .' 85-86 Comparison with thymol, summarized from Report of Uncina- riasis Commission to Orient 86-87 Interval between treatment and re-examination 87-88 Given on sugar 88 Preparation of capsules 88-89 Relation of drop to minim 89 Cases of poisoning 89-91 Gastro-intestinal symptoms of poisoning 91-92 Neuro-toxic symptoms of poisoning 9I> 92-93 Aural phenomena in poisoning 93 Remarks of Salant and Livingston on depressing quaHties 93 Treatment for poisoning 93-94 Cardiac symptoms in poisoning 94 Value as a vermifuge 94 Capsules required for one gallon 167 Contraindicated 169 Also 49 See also Non-treatable Cases; Supplies INDEX 185 PACE Oils and Fats, Solubility of Thymol in 79 Oliver, Sir Thomas 17-18 Panama 90 Per Capita Cost, see Treatment, Per Capita Cost of Peter's Hall District, see British Guiana Poisoning, see Non-treatable Cases; Oil of Chenopodium; Thymol Portuguese, in West Indies 24, 103 Pregnancy, and Treatment for Hookworm Disease, 72,83-84, 169, 170 Prest-O-lite Gas Tanks, see Supplies Publicity Work, see Intensive Method in Hookworm Control; Lectures; Literature; Nurses Purgatives, see Castor Oil; Epsom Salts; Senna; Sulphate OF Magnesia Reports: Microscopic Report Sheet: Explanation and sample page 131-133 Nurses' Daily Report Sheet: Explanation and sample page 134, 138-139 Nurses' Weekly Report Sheet: Explanation and sample page 135, 140, 141 Nurses' Weekly Summary Report Sheet: Explanation and sample page 135, 142, 143 Diary: Record of educational work, with sample page 144-146 Geographical area report on completed work 146, 148-149 Quarterly report on completed work with sample page. . 146, 150-15 1 Quarterly report on work in progress, with sample page. . 147, 152-153 Special monthly report for Regional Directors, with sample page 147, 154 Narrative report 147, 155 Budget: Explanation, and sample form ISS~IS7 Salaries 158-159 Office equipment 159 Scientific equipment 160 Drugs 160-161, 164 Contingent fund 164 Quarterly and yearly financial reports, with sample form 162-164 Rockefeller, John D., Jr.: Member International Health Board 5 l86 INDEX PAGE Rockefeller Sanitary Commission 23 Rose, Wickliffe: General Director, International Health Board 5 Also 22 St. Lucia: Table showing per capita cost of hookworm campaign lox Results of treatment, with table giving percentage remaining uncured 121-122 Also 58 St. Vincent: Table showing per capita cost of hookworm campaign loi Results of treatment, with table giving percentage remaining uncured 121-122 Also 58, 103 Salant and Livingston: Remarks on depressing qualities of chenopodium 93 Salant and Nelson, Toxicity of Oil of Chenopodium, quoted. . . 90 Salaries 51-52 See also Budget, under Reports Salines, see Epsom Salts Salt, see Sulphate of Iron Schuffner and Vervoort: Method of treatment with chenopodium 84 Scientific Equipment, see Budget, under Reports; Supplies Seiton, Dr. Samuel, quoted 93 Senna, in Thymol Poisoning 82 Sewage Disposal, see Latrines; Soil Pollution Smear Method, Direct, see Laboratory Technique Society of Tropical Medicine and Hygiene, quoted 17 Soda, in Treatment for Gastric Irritation 81 Soil Pollution: Necessary to hookworm infection 14 Installation and use of sanitary conveniences 16-17 Prevention in West Indies 16-18 Importance of prevention 95 Survey of latrine accommodations 9S~96 See also Latrines Southern States: Thymol treatment 74 Fatal cases of chenopodium poisoning 89-90 Specimen Containers, see Feces, Examination of; Supplies Staff, see Working Staff Standard Method, see Laboratory Technique INDEX 187 PAGE Stewart Panhead, see Centrifuge Stimulants in Thymol Poisoning 83 Strychnine: In thymol poisoning with dosage 83 In chenopodium poisoning 94 Sugar, Oil of Chenopodium given on 88 Sugar of Milk Combined with thymol 77-78, 160-161 Sulphate of Iron In destruction of hookworm larvae in soil 17-18 Sulphate of Magnesia: In treatment with chenopodium 73, 81, 86, 90, 91 Annual estimate of amount for one unit of force and cost of same. 161 Dosage for adults and children 161 Also 169, 170-171 See also Supplies Sumatra: Weiss method of administering chenopodium 8S>9I Supplies: Procurable through International Health Board, with list of prices 165-167 Talquist, Hemoglobin Scale Books 165 Technique, see Laboratory Tecnhique Thymol: Methods of administering, and dosage 69, 71-72 Amount necessary to cure one adult '. . . .70, i6a-i6i Results of treatment by daily dose method in Peter's Hall district 70-71 Maximum dose for adult 71 Persons medically unfit for treatment 72 Treatment preceded by thoracic examination 72 Directions for treatment by weekly dose method 72-74 Intervals between treatment and re-examination 74~7S Number of treatments necessary and percentage of cures 7S Safety as a drug 76 Combined with sugar of milk 77~7^ Toxic effects and solubility 79-8o Symptoms of poisoning 80-82 Treatment for poisoning 82-83 Use during pregnancy 84 Comparison with chenopodium, summarized from Report of Uncinariasis Commission to Orient 86-87 Capsule form and cost of same 160-161, 166 l88 INDEX PAGE Thymol — continued Annual estimate of amount for one unit of force and cost of same 160-161 Dosage for children 161 Contraindicated 169 Directions to nurses for treatment 170-171 Also 49-50 See also Non-treatable Cases; Supplies Tobago 58 Toothpicks, in Laboratory Technique S9> 60 See also Supplies Toxicity of Oil of Chenopodium, by Salant and Nelson, quoted 90 Treatment, Per Capita Cost of 99-102 Treatment Book: Description, with sample page 134, 136-137 Treatment of Hookworm Infection, by Uncinariasis Commission to the Orient, quoted 86-87 Trinidad: Quarterly average of persons examined, treated, and cured. . . .27-28 Technique of examinations, with comparison of methods 57~5^ Table showing positive findings after centrifuging 64 Observations on use of thymol, with table giving percentage of cures 76-78 Interval between treatment with chenopodium and re-exami- nation 88 Table showing per capita cost of hookworm campaign loi Dr. Washburn's report, quoted 108 Result of treatment by intensive method, with table giving per- centage remaining uncured 121-122 Also 58, 68, 103 Tubes, see Supplies Uncinariasis, see Hookworm Disease Uncinariasis Commission to the Orient: Recommendations on use of chenopodium 85-86 Summary of report on comparative value of thymol and cheno- podium 86-87 Recommendations on interval between treatment with cheno- podium and re-examination 88 Experience on toxicity of chenopodium 90-91 Unit of Force, see Working Staff Vermifuges, see Oil of Chenopodium; Thymol Vertigo, in Poisoning, see Oil of Chenopodium; Thymol INDEX 189 Vials, see Supplies p^^^ Vincent, George E.: Chairman International Health Board 5 Washburn, Dr. B. E.: Observations on use of thymol with percentage of cures 76-78 Results of experiments with chenopodium 88 Report of ankylostomiasis campaign in Trinidad, quoted 106-108 Also. .note 57 Weiss Method of Treatment of Chenopodium 85,91 Welch, Dr. William H. Member International Health Board 5 West Indies: Prevention of soil pollution 16-18, 95 Elements of population 24, 103 Temperament of population 26 Rate of hookworm infection 27 Difliculties in organizing laboratory force 56 Method of reckoning per capita cost of campaign, with table. .99-102 Feasibility of intensive method 103-104 Also 40, 62, 90 Sif^a/jo Intensive Method; Oil of Chenopodium; Thymol; Working Staff; also Names of Islands Working Staff: Efforts concentrated on small area 26-27 Results in Trinidad and British Guiana 27-29 Size and elements 37~38 Cost of maintenance and method of conducting work 38 Concentration of efforts 38-39 Branch offices established 39 Duties of clerical force 42-43 Duties of caretakers 51 • Salary of chief clerk 51 Number of infected people treated in one year 160 See also Medical Director; Microscopists; Nurses / University of California SOUTHERN REGIONAL LIBRARY FACILITY 405 Hilgard Avenue, Los Angeles, CA 90024-1388 Return this material to the library from which it was borrowed. 985 DE Ni Form ^c: '^7l 58 00373 4133 Vt M •^7ir)N'