Victor G. Heiser.

Annual Report of the Bureau of Health for the Philippine Islands online

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nouncement card for the purpose of giving notice of the arrival of the
inspector; a card of instniction, especially for the employers of labor,
showing how the hookworm may be su|)presse(l ; and a treatment card.

The instruction card used in Porto Rico, under the heading of
''Instruction to farm owners concerning the suppression of anemia in
Porto Hico," bore the following information:

Anemia is the disease from wliicli the majority of our country folks suffer.

It alone causes more deaths than all other diseases.

Those peons and others that you are shelterinj^ and that work for you are not
strong because they are anemic.

Should they become cured they would l>e better workmen.

Send them to us that we may cure and teach them to prevent the disease.

To prevent anemia remember that it comes from ground-itch (mazamorra) ;
that ground itch (mazamorra) is only contracted where there has been earth
soiling; that to avoid ground-itch it is well to use hose. So advise your people.

But it is still more imporUnt that each house have its privy and that no one
defecate on the surface of the ground.

Prohibit your peons from defecating while at work on the plantation unless
they cover each stool with a little earth that may be scraped up with a cutlass
( machete).

Thus the excrement is covered and the worms killed.

While it was not expected that every farm owner would comply with
all these instructions or that it were possible to produce ideal conditions,
the results were more satisfactory than had been anticipated.



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If the hookworm caused directly more deaths in Porto Rico than any
other disease, what an alarming array of charges could be brought
against this pest if it were called upon to plead to an indictment from
the whole world for all the deaths that it is indirectly responsible for
through its devitalizing influence on its victims and its profound im-
press on their offspring. Children born of anemic parents can not
possibly possess that degree of vital resistance necessary to tide them
over the critical period of early infancy.

The life history of the hookworm when told in popular narrative
style is more interesting than a novel, and could be made the subject of
lectures, popular talks, and personal conversations without trespassing
on the domain of delicacy. Sir Patrick Manson, the great English
authority on tropical diseases, has so popularized the whole field of
tropical medicine in the lecture courses which he has given in nearly
every part of the world that it has been possible to adapt from his
beautiful discourses a popular circular on the hookworm disease that can
not fail to interest, instruct, and benefit the Filipino people. This
Bureau has now in course of preparation a simple language text which
is to be used as the basis of the didactic instructions and general infor-
mation circulars under contemplation. This text, in treating of the hook-
worm, takes up the question in its relation to anemia. The rough outline
of the circular in speaking of uncinariasis is to the effect that "hook-
worm disease is not a new disease that has been discovered, but it is an
old one formerly called anemia grave, anemia pemiciosa, and falta de
la sangre/' This often grave condition is dependent on the presence in
the intestinal tract of a hookworm. The worm is very insignificant in
size, but in consequence of the local irritation and vitiating action on
the blood due to its food necessities, and to a poisonous substance called
toxin which it is believed to secrete, this innocent-appearing parasite
brings about a condition of anemia in its host; that is, in the person in
whom the worm exists. This anemia always produces a marked weakness
which may lead to serious disease or death, and which, when affecting
one or both parents, nearly always results in weakly, sickly children,
who often die in early infancy or fall victims to this or some other
disease during childhood. This is one of the reasons why so many Fi-
lipino babies and children die. The bodies that they have inherited
from diseased, anemic parents, can not withstand the germs of tuber-
culosis, malarial fever, amoebic dysentery^, and other diseases of this
class, or even the unfavorable changes in the weather, so they die before
their time.

In view of the fact that anemia is a very common disease in the
Philippines and that it is robbing the parents of their children and the
children of their parents, and producing sickness and distress of so serious
a nature, it is of the greatest importance that the people should learn



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something about the cause for all this, which is nothing more tlian a
little worm that finds its way into the intestinal tract and attaches itself
by two little hooks to the mucous or inner coat of the intestines and
thus gets its food at the expense of the host. These worms do not
occur singly but in great numbers; the more numerous they are, the
more grave will be the disease caused by them. They live in the small
intestine and lay their eggs into the contents of the bowels, whence they
escape with the feces. If the eggs, after they have thus passed out, are
kept warm in a suitable medium such a« damp earth, they hatch out and
a very small and at first very active little worm or embryo, so tiny that
it can be seen only by the aid of a magnifying glass, is set free. Thefle
little creatures rapidly acquire organs of digestion, and after casting
their skins several times, and undergoing other changes to fit them for
their subsequent life, they are ready to reenter another human being;
the person who is so unfortunate as to be the one into whom the worms
enter being called their host, because he supplies them with food and
with a home in his intestinal tract.

It is known now precisely how reentry is often, if not always, accom-
plished. It was formerly believed that the young parasite entered the
human alimentary canal by being swallowed in dirty water or being
transferred on earth-soiled hands or dishes to the mouth and thence
to the stomach, but later investigations have shown that the most com-
mon method of infection is by a different route. The little worm
penetrates the skin, generally that of the feet or legs, of persons passing
through or working barefooted in or otherwise being brought into
contract with earth in which the eggs of the hookworm have been
deposited. The young worm enters the skin through some follicle,
thence passes into a blood vessel which carries it to the heart, from wiiich
organ it pa«;ses by the pulmonary vein to the lungs, where it leaves the
blood vessels and undergoes further changes for the purpose of enabling
it to withstand the action of the gastric or stomach juice. The worm
is on its way to the small intestine, its permanent abiding place, which
it must reach before it can reproduce its kind. To get from the lungs
to its final resting-place, it enters an air vesicle in the lung and from
the air vesicle it finds its way into one of the little tubes that carry
air into the lungs and so on, by the way of the windpipe, into which
the smaller tube leads, thence upward until it can get into the lower part
of the throat, find its way into the tube leading to the stomach, through
which organ it passes and enters the small intestine, where it makes
itself at home and begins in its peculiar way to raise a family by produe-^
ing eggs destined to pass out of the bowel, hatch in damp warm earth,
and begin the round again.

The most critical period in the life history of the little creature la
the time when it is outside of the human body; millions of eggs are



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destroyed by unfavorable conditions and countless numbers of young
worms lose their lives because they can not find an opportunity to con-
tinue their existence in human hosts. Should the temperature of the
medium in which the young parasite is lying fall below a certain point,
the necessary developmental changes are suspended or never commenced.
Filipinos are quite familiar with a form of itch called mazamorra or
ground-itch This is an inflammation of the skin generally attacking the
feet and legs, but at times other surfaces as well. The inflamed parts
itch very severely and often become infected through scratching. Dr.
Loos, a man who has studied this disease a great deal, has shown that
the condition called ground-itch, or mazamorra, is produced by the en-
trance of the little hookworms through the skin; in other words, that it
is but a manifestation of the presence of the hookworm disease. Sir
Patrick Manson, an English physician who is a professor of tropical
medicine in the great London University, in one of the several books
he has written, tells a story of a planter living in the West Indies who
told him how at one time he was seriously inconvenienced by mazamorra
among his farm hands. He noticed that this trouble was followed by
profound anemia and also that the skin disease and anemia occurred
principally among the employees who worked in or passed through
certain fields of his plantation. The weather in the West Indies is
warm, as it is in the Philippines, and the working people go without
shoes and stockings, from which fact the planter argued that in these
particular fields there were certain germs that, coming in contact with
the legs and feet of the laborers, produced first the skin disease, and
later on, after they had entered another part of the body, the anemia ;
so this observing man, believing that the disease was a germ or bacterium,
sought to find some remedy to circumvent or kill it. In thinking on
this subject he remembered a certain practice that he had seen in
Germany where he had frequently gone for his health. In that partic-
ular part of the German Empire to which he was accustomed to go,
geese are raised in large numbers. The goose market is a long way
from the goose farms, so that the geese when ready for sale have to be
driven for many miles over the hard roads. To enable them to stand
\.\\Q journey, the farmers provided them with close-fitting antiseptic
socks or sandals, made by filling a shallow trough with tar, and through
the trough the geese were driven onto a piece of ground covered with a
layer of fine sand. The tar stuck to their feet and the sand to the
tar, and thus they were provided for their long journey. The planter,
acting on the suggestion offered by this practice, had his laborers dip
their feet in a bucket of tar and then walk across a layer of sand or
sawdust. The result was that no more ground-itch was contracted
because the skin was protected by the coating from the little worms.
Other incidents could be related to show how easy it is to prevent the
disease, but the matter is too plain to require further explanation.



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The first step in determining the presence of the disease is to suspect
it. The next is to consult the local board of health or the local president
who will be able to give advice as to when tlie physician engaged in this
special work may be seen.

The local physicians have for free distribution little cards with full
directions that must be followed before, during, and after treatment
Xhe cases will be examined by the physician, and he, at the same time,
will determine the ditignosis and administer the treatment.

The opportunity is now presented for the people of the Philippine
Islands to be cured of a very dangerous disease^ — one that pre))ares the
way for many others. The coojx'ration and helj) of all is earnestly
desired.

One of the main reasons why there is advcx'ated elsewhere in this
report the introduction of silkworm raising and the fertilization of the
mulberr}' trees by human ft\M*s that have been ex}>(>s(Ml to ctM'tain di^
structive pnK'esses, is that only by making such feces of commercial
value will there be enough interest taken in the (jiustion of the deposit
of night soil as to insure otricial regulation.

The combating of tlie hookworm disease is certainly a large un<lertak-
ing and to those wlio are not familiar with wluit, in the light of past
experience, has bcM'n brought within the range of ]>os8ibilities, the whole
proposition may appear as a chimerical dream. Hut it can be done,
and if nothing occurs to ])revent the execution of th(» plans, it will
bo done.

The Phili])pine Islands Medical .\ssociation at its last annual nu»et-
ing showed its interest in \\w gn^at ])rol)leni by j)a.'ising the following
resolutions:

Whereas it appears tliat tlie treatment of tlje prisoners for intestinal worms
has been an im|X)rtant factor in reducing the <leath rate at Hilibid Prison; and

Whereas it would appear further that over tliree-fourths of tlie jwpulation of
tlie Philippines is at the present time infected with animal parasites; and

Whereas infection with these parasites can Ik* controlled almost absolutely by
properly disposing of the human excreta wliich contains ova of the parasites; and

Whereas the proper disposal of human excreta will at the same time remove
one of the most dangerous channels for the dissemination of otlier fnfectious
diseases: Therefore, be it

Resolved, That the Philippine Islands Medical Association shall |)etition the
Government of the Philippine Islands, through the Honorable Dean C. Wf)rcester,
Secretary of tlie Interior, that a commission of five properly qualified members
be appointed to decide upon tlie most practicable and effectual means for the
proper disposal of human excreta that can be established in these Islands.

Be it further resolved. That the (Jovernment of the Philippine Islands be
petitioned to make such appropriation and provide such amounts for the establish-
ment of a working system for the disjwsal of human excreta as from the report
of this commission may appear practical and expedient.

It is not believed that the people, when they understand the matter,
which they can not fail to do wdien the Bureau of Health has carried
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out its plans of sanitary mission appeals, will show any hostility to the
movement, as the work will be carried on by the local officers so far as
practicable.

Special effoit will be made to avoid technical expressions in the
circular as it is intended to use it as a basis of popular and public
enlightenment. The part relating to treatment has not been given, as
the details of this part of the plan have not as yet been worked out^

LEPR08T.

Work on the projwt which had for its object the segregation of every
leper in the Philippine Islands at Culion was actually commenced during
the month of May, 190G. Up to that time the relief extended to lepers
was more in the nature of aiding the individual lei)er; the larger project
of extemiinating this disease from the Archipelago was never seriously
undertaken. In view of the conflicting opinions as to whether seg-
regation could accomplish this, and the question of financing so large
a project, considerable delay was caused in starting this undertaking.

'J'he experience of the past two years, while not yet sufficient to form
definite conclusions, is strongly indicative of the fact that not only will
the disease be extenninated, but that the project will prove to have
been most advantageous from a financial point of view. The foregoing
is from the purely utilitarian standpoint ; but viewing it from the
lai-ger, and, of course, first to be considered, humanitarian standpoint,
tlie care of all of these unfortunates will redound to the credit of
America as an act that will receive favorable comment throughout the
civilized world.

x\t the time the work was commenced, it is estimated that there were
at least 3,500 lepers in the Islands; at the end of the first year there
were 2,820 ; at the end of the present fiscal year the number was 2,486.
The reduction in the number during the first year resulted largely from
the fact that persons who lived in the Islands of Samar, Leyte, Masbate,
Eomblon, and Negros who were classified as lepers were found to be
. suffering from other diseases. Not the least of the benefits derived by
the collection of lepers in the provinces is the fact that many persons
who had for years been outcasts from society on account of being afflicted
with diseases that resembled leprosy were treated for the maladies from
which they actually suffered and have again been restored to their
rightful social status.

During the past year instead of finding less lepei-s than the I'eports
showed, in a number of provinces many more were found. For instance,
in the Province of x^lbay there were 57 reported. After the examination
of all the suspects was completed, 317 were found positive. In Camarines
instead of 33 there were 42. In Sorsogon instead of 87 there were 121.

These increases fully offset the erroneous diagnoses of the previous
year, so that we must look for other reasons to account for the decreased



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luiniber this year over that of the preceding. In view of tlie fact that
953 lepers were remove^] to Culion last year and 1,554 this year, it is
certiiin that at least thi^i nuniher of foci of infection was obliterated,
and the opportunity of contractinjj: leprosy was just that much reduced.

From the foregoin^^ it is estimated that at least three hundred less
persons contracted the disease. The advan(a^^» accruing therefrom will
at once be apparent. Not only have over thrw hundred unfortunates
been saved from this, the most, hopeless and loathsome of all human
diseases, but just that many less charges have been thrown upon the
body politic, and three hundred nonproducers have been held in the
pro<lucing class.

The actual work of collecting the lopci-s nud caring for them after
they are collected still presents obstacles, many of which at times seem
unsurmountable. Regardless of what the opiiiicm of |HM)ple may be in
the abstract, when it comes to persons who will do actual work of trans-
porting tliem to a seaport, |)roviding their subsisttnice, aiding them
aboard tiie steamers, making the necessary medical examination, at-
tending to their needs, ex}>eriencc has again and again demonstrated that
tliey are most difficult to find and only persons with su])erior courage
can he induced to continue at the work. One of the greatest aids has
been the enactment of Act No. 1711. entitled *'An Act |)rovi(ling for
the appivhension, detention, segregation, and treatment of lepers in
tiie riiiiip])ine Islands."

The practice of making a careful microscopical examination of each
case has I)een faithfully carricxl out, and no doubt is largely responsible
for the confidence whicli is disi)laycHl in the diagnoses made by the
medical officers of this Bureau.

The attitude of the people of tlie Islands as a whole toward segre-
gation has been most gratifying. There is probably no place where
family ties are closer tlian in the Philippine Islands. In spite of the
fact that it has frequently bc^n necessary to separate husband from wife,
mother from child, brother from sister, fri9nd from friend, they resign
themselves to their fate and in addition frequently aid the representatives
of the law whose duty it is to carry out the segregation, when it is ex-
plained that such action is necessary for the good of the many. With the
exception of a few isolated instances, tlie collection of the lepers has been
carried on without any marked opposition or disorder. The only se-
rious accident is that whicli occurred at Malitbog, Leyte, at which place
two lepers became involved in a quarrel, as a result of which one was
fatally stabbed. However, quarrels of this kind are not confined to
lepers, and scarcely can be said to be connected with the question of
segregation.

A frequent experience perhaps worthy of mention is the practice
of many municipalites presenting their insane, blind, cripples, and



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other incurables who have become public charges, for transfer to Culion.
These of course can not be taken care of upon a leper island, but when
they ar6 not taken away much surprise is often shown.

The Provinces of Mindoro, Masbate, Romblon, Capiz, Iloilo, Antique,
Oriental and Occidental Negros, Samar, and Leyte, have already been
gone over two or more times, and with the exception of a few isolated
cases, may be said to be free of lepers. The Provinces of Cebu, Bohol,
Ambos Camarines, Albay, BatangaB, Tayabas, Sorsogon, Benguet, Le-
panto-Bontoc, and Ilocos Sur have been gone over once, but are not yet
regarded as being free of lepers, and they will necessarily have to be
searched over one or more times again.

The present Legislature has made ample appropriation for continuing
the work during the coming fiscal year along the lines mapped out by
the Philippine Commission during the year just closed.

At the colony proper much work was accomplished, but it has not
yet even commenced to assume the appearance it is hoped it will liave
when the permanent improvements have been installed. The constant
idea has been to make the colony, at least temporarily, liabi table in the
shortest possible time for the total number of lepers in the Islands, so that
the opportunities for contracting the disease may be reduced to the
smallest limits, and the drain on the resources of the Islands decreased
as soon as possible. This plan also has the advantage of keeping the
Bureau inforaied as to approximately how many lepers will have to be
cared for at Culion for many years to come, and thereby makes it
possible to regulate the extent and character of the permanent improve-
ments to be made.

The Bureau of Health has not only provided all of the medical care and
attendance required, but has carried on the construction work as well.
Even construction work in the Philippines under the direct charge of
the technical Bureau of the Government created for that purpose is
attended with many difficulties, such as lack of labor, skilled superin-
tendence, difficulty of obtaining supplies, torrential rains, and many
other obstacles; but it sinks into insignificance when compared with
construction work on a leper island, that has a steamer call only about
once a montli, and where labor goes with fear and trembling, often
deserting in a body, and where trained superintendence is scarcely obtain-
able. It is for this reason that particular credit is due to the medical
and other officers connected with the Bureau of Health for the results
which have been obtained. The construction work done at Culion will
compare favorably in character and cost with that done elsewhere.

A reenforced-concrete warehouse has been completed and a 100-bed
hospital of the same material is now in course of construction. The
work on the hospital is being delayed by the difficulty in obtaining
laborers on account of their fear and dread of the disease.



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So far it has not been found practicable to liave the lepers do work
other than that entailed bv their own domestic requirement*. This
course has been adopted in deference to their physical condition, and
in respect to tiieir innate disposition to take life easy, which after all
is not a bad thing in lej)ers.

The niortiility at the colony still rcniains high, but it is believed that
it is materially lower than it would have been among these same people
in their homes, as many of them were beggars and wholly dependent
on public charity for their living. The great nuijority of cases wer(»
so far advanced when they were received into the colony as to render
them beyond human aid; those who arrived in a reasonably fair con-
dition have gained in weight and strength antl are apparently happier,
healthier, and better satislitnl then they were in their native provinces.
The work of the hospital staff htis been exceedingly trying and disgusting
owing to the ]>revalence of gangrenous ulcers among the new arrivals,
the treatment of a single patient often requiring more time than a major
surgical o})eration. As soon as the hospital now in procc^ss of construc-
tion is completetl, the cjuestion of treatment will be greatly simplified by
the increased facilities and more favorable conditions.

X-HAY THKATMKNT OF LKPHOSV.

During the fiscal year treatment of lepers in the San Lazaro Hospital
with the X-ray has been continued. The results in 'M) selected cases
are as follows: Apparently cured, 1; markinily improved, 5; improved,
7; died, 2; the foregoing 30 cases include the 21) persons who were
mentioned as being under treatment in the last annual report. One of
these died of chronic amcebic dysentery, and the other from puerperal


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Online LibraryVictor G. HeiserAnnual Report of the Bureau of Health for the Philippine Islands → online text (page 8 of 20)