from the stools, which were washed slowly down thought was, "Has the new anthelmintic, betaa trough painted black, the stool having first napthol, said to be at times a renal irritant, anybeen filtered through gauze. In a report on thing to do with this condition?" The second, ankylostomiasis by Löbker and Bruns, 1906," Is there a latent renal lesion present in the we find the following: disease?" To determine these facts an addi"The views of Loos were substantiated by tional series of cases were taken and our results Schaudinn, after a careful re-examination of a follow with conclusions; but before considering large number of Leichtenstern's sections, when these tables a few explanatory remarks should the intestinal contents of the ankylostoma were be made: microscopically examined. Among 300 worms selected at random, he found 196 whose intestines contained cell fragments other than blood cells. In the remainder he found either nothing or else blood cells to a greater or lesser amount. Repeatedly long strips of intestinal membrane were traced, completely extending from the mouth through the alimentary canal into the intestine of the worm." It was manifestly out of the question, for lack of time, to make complete quantitative urinalyses as we desired. The day was so split up by other work and other investigation that it was decided to elicit certain facts only, and these with great care, so that a definite conclusion could be reached. It was evident that an examination of the urinary sediment, as well as a determination of This is important information when we remem- the presence or absence of albumin, should be ber that Leichtenstern was the observer of all made. In order to offer a series of cases carried observers who was most identified with the far enough to furnish evidence that would be teaching that ankylostoma duodenale was not satisfactory, the continued presence of the paonly a blood sucker but was so prodigal of his tients in hospital was necessary, and this was food that he consumed blood entire to appropriate precisely the most difficult part of the problem, only the serum, evacuating blood cells practically as when they felt better they clamored to unchanged. For this the noted authority dubbed go back to work and stood not on the order of the worm, "the luxurious parasite." their going but frequently went, spoiling for us The urine in uncinariasis before and after many hours of toil. The original number of treatment. In the first report of the Porto such cases is, therefore, reduced to twenty-four. Rico Anemia Commission it is stated that albu- The practical impossibility of obtaining the min is rarely found, although note is made that twenty-four hours' urine and the numerous the kidneys may be very pale and slightly fatty, time-consuming details to which we were obliged sometimes being the seat of parenchymatous to attend personally, prevented us from making or interstitial inflammation, sometimes of amyloid urea estimations. One of the occasions at which degeneration but, generally speaking, without the urinary examination was needed was that marked involvement of these organs. - at which purges had to be administered, and Three tests were always used at We would like to considerably modify our former opinion. It was based on the examination of a series of cases but was not made, as was the blood, a matter of special study, inasmuch as Heller's nitric acid test and the absence of clinical evidence gave us no clew to the real condition. It is significant that writers on uncinariasis make practically the same statement. As a matter of fact, the condition of the kidney in a well-marked case of uncinariasis is of the greatest importance, as will be shown. We noted the irritant effect of the anthelmintic drugs employed upon the digestive tract and found albuminuria after their administration, in accord with the (1) The boiling of urine with a drop of two or experience of Loebker and Bruns, Calmette, acetic acid to six parts urine and one part satuSiccardi, and others with thymol and male fern. rated salt solution, the test tube nearly full and Our plan for 1905, among other things, was the upper half boiled to compare with the unto make a careful study of the therapy of unci- boiled lower half in a good light against a dark nariasis and to that end a series of cases was background. We were aware that a very faint studied in which the uncinaria expelled were clouding could be thus obtained in many normal counted after each anthelmintic dose. This, to- urines. (2) The ferro-cyanide of potash test. gether with manifold other duties, consumed about (3) Heller's nitric acid test. When the first was all the time available from the actual adminis- faintly positive and the last negative, a slight trace tration of so large a work as the treatment of was noted; when the latter was positive in a faint some 25,000 persons. but characteristic ring, not disappearing on heatFrom the first, however, our attention was ing, a trace was noted. Only a very few times was attracted by one case to the immediate and albumin found in considerable amount. Ordinaimperative duty of more carefully investigating rily the amount was so small that its percentage the urine. This was one in which nephritis could not have been determined by the Esbach occurred during treatment. Naturally, the first albuminometer. The sediment was collected after standing some hours in conical test glasses and but twice in this series. These two doses were the urine was not centrifugalized. The casts given successively to the same patient, 2 and were generally of the smaller varieties, hyaline 4 gm. respectively, and resulted in the expuland finely granular forms predominating. Blood sion of only two uncinariæ. The alcoholic excasts were not seen in this series and epithelial tract was used in each instance and it was precasts were uncommon. Fatty casts were quite sumably fresh as it was employed immediately often noted. The presence of polymorphonuclear after it arrived by mail from one of the best leucocytes was at times discovered before the known pharmaceutical firms in the United States. administration of the anthelmintic, and there This was not the only occasion upon which we was a tendency for them to appear, sometimes used male fern, and its failure to expel Necator in fair numbers, afterwards. Renal cells were Americanus was observed in several other trials not a very marked feature and were almost where the preparations of other firms were used. always scarce. In this particular case this observation was Urobilin was almost always present, fluores-especially interesting as one week after the fruitcence by the zinc chloride test being elicited, less administration of male fern only 3 gm. of but it was often remarkably slight. thymol were given and by this one dose 3,686 Peptones in traces were found to be inconstant uncinariæ were expelled from the same patient. but often demonstrable. Of the 23 who expelled uncinariæ, in 1 case Indican in abundance, as Siccardi recently the worms were not counted. In the rest, 9 states, was a very constant and persistent phe- expelled less than 300 and of these 2 had no nomenon. Bile pigment was relatively rarely found. A most interesting fact was the invariable absence of the diazo-reaction, save immediately after the administration of beta-naphthol, in 1- or 2-gm. doses, when it never failed. Its presence was demonstrable three to four hours after the dose and its effect lasted five or six hours. The next day it was always absent. When it was present it was beautifully pronounced and was an unfailing evidence of whether or not the drug had been taken. The color of the urine. was frequently some shade of olive after thymol, a color developing or deepening on standing in the open air. Apparently, beta-napthhol did not affect the color of the urine. The reaction was practically always acid, rarely alkaline or neutral, as Calmette found in his cases. The specific gravity tended to be low but almost always increased under medication. Sugar was not found to be present. Photographed by Dr. W. M. Gray. FIG. 2. Necator Americanus attached to the human jejunum. x 200 diameters. From the tabulation of the twenty-four cases in which successive urinalyses were made the following condensed statement embraces the essential facts: 18 were males, 6 were females. Seven under fifteen years of age; 12 were between albumin in their urine before the administration fifteen and thirty; 5 were over thirty. One case of the anthelmintic; 5 had a slight trace; 1 a expelled no uncinariæ, had no symptoms of the trace; 1 a considerable amount. Eight expelled disease but expelled 418 oxyurides in two doses between 300 and 1,000 uncinariæ and of these of beta-naphthol (all she harbored). Two of 1 showed no albumin before treatment; 6, a the remaining 23 were suffering from a very slight trace; 1 a considerable amount. Three light form of uncinariasis; 3 from a light grade; expelled between 1,000 and 2,000 and of these 4, moderate; 10, intense; 4, very intense. 2 showed a slight trace and 1 a trace of albumin Thymol was the only drug employed in 10 cases; before the drug. Those who expelled more than thymol and male fern in one case; beta-naphthol 2,000 uncinaria (one 2,749; the other 4,397, the alone in 13. The total number of doses of thymol was 45 and of beta-naphthol, 62. The dose of thymol was 2 gm. in children, and from 3 gm. to 4 gm. in adults; that of beta-naphthol 1 Of the total of 24 cases, 20, or 83.3%, are seen gm. in children, and from 1 gm. to 2 gm. in adults. to have had albumin in the urine before the adThese doses were always preceded the night before ministration of anthelmintics. One of these by sodium sulphate and followed in two hours by cases was not one of uncinariasis and had no the same drug. The anthelmintics were always albumin nor casts, but developed a very slight administered by dividing the dose above men- trace of albumin under treatment. In 18 of tioned into two equal parts, one given at 8 these 20 cases, or 75%, casts were also demonand the other at 10 A.M. Male fern was given strated. Generally the casts were very few in largest number expelled in our series of worm counts) gave only slight traces of albumin before treatment, demonstrable solely by boiling. number; in only 6 of the 18 were they at all 4. The casts are generally hyaline, finely abundant. The average hemoglobin in those granular and fatty; rarely epithelial unless the persons showing albumin before the administra- epithelial cells are very fatty when they are tion of the anthelmintic was 46.1%; that of the classed as fatty casts. Blood casts are very 4 who had no albumin before the dose was 80.5%. rare. Sixteen of the 20 cases showing albumin before taking the specific drugs had but a slight trace; 1 a trace; 3 a fairly abundant amount. Albumin increased in amount under treatment in 15 cases and appeared for the first time after the anthelmintic in 4, a total of 19. Albumin did not increase under treatment in 5 cases, although it existed at the beginning. Finally, of the 220 urine records here recited, 118, or 53.63%, showed Twenty-seven, 6. Albuminuria with casts in uncinariasis should be regarded as the evidence of a degen- erative process in the kidney, not as an inflam- mation or, more specifically, a nephritis. 7. Both thymol and beta-naphthol can act as renal irritants, especially in the presence of 8. While ordinarily these drugs cause an in- crease in albuminuria and often bring it about where before it was absent, their effect is tem- porary, causes no symptoms in the vast majority of cases and is rarely of importance. 9. There is almost always an absence of in- flammatory elements after the above-mentioned 10. Very rarely they may set up a severe 11. The cases herein cited show that both drugs seem to have an equal power to increase in albuminuria with tube casts, but our experience over a large number of cases demonstrates to us that, all things considered, beta-naphthol has a very much less favorable action on the kidney and that it is not as safe as thymol for this reason, although its depressant effect is not so marked. Thymol has not, in our experience, caused fatal 12. Albuminuria does not always seem to de- pend upon the grade of anemia. 13. Albuminuria and the changes found in the kidney after death may be due to a specific toxin and 22, or 10%, much albumin. Conclusions. Our conclusions are not based i. Albuminuria with tube-casts is a very com- mon phenomenon in uncinariasis. 2. It may be present in light or severe cases, 3. Albumin is present generally in very slight traces, not discernable by the Heller nitric acid 15. Emphasis must be laid on the fact that 16. Renal accidents from the use of the anthel- mortality should make us disregard the remote danger to the patient from the use of thymol. 17. The use of beta-naphthol should be re- stricted to very few doses and its administration should be limited to patients in extreme grades effect on the vital centers, until enough uncinariæ were those of temperate zones and he is apt to are expelled to create a favorable reaction and explain the phenomena of disease according to enable us to use thymol. However employed, a the light he received. dose of 2 gm. should not be exceeded and no more than three successive doses given, one each week. In concluding this paper we desire to call attention to the possibilities for scientific investigation in the work which the Porto Rico Anemia Commission is now accomplishing. There should be some way of acquainting American and Porto Rican physicians with special features of preventable disease in that island where such efforts are being made to carry the principles of the science of medicine into practice. As it is, men who are not satisfied to trust to The insular government is doing all in its tradition to solve the problem arising in their power to conquer the reigning disease of its work-professional life grope aimlessly about for some ing classes but for some time this compaign must center where they may work out for themselves, be vigorously pushed to restore health and to or have worked out, those facts which alone can save life. Face to face with an enormous number be resolved in a well-appointed laboratory. of sick it would be manifestly impossible to divert Such a center, by interesting all physicians funds for the further investigation of the diseases who come in contact with the poor on the one of the island in a well-equipped laboratory, yet hand and local officials on the other, would be such an institution is urgently needed, as none able to carry the authority derived from facts realize more fully than the commission itself. and figures into their great task of sanitary reform. To the honor of the physicians of Porto Rico let it be said that they have equipped themselves with microscopes and a few of the more necessary clinical laboratory instruments, from their own personal resources. This is not confined to one or two but is general among the large number THE recent investigation of health conditions who see the necessity for recourse to so valuable of industrial life by the State Board of Health an aid to diagnosis. This fact more than all of Massachusetts is the first definite step in the others demonstrates the active and intelligent development in America of industrial hygiene. interest in medical progress in Porto Rico and For this step credit belongs to the promoters of bespeaks a spirit which merits support. the necessary legislation, to the legislatures of 1904 and 1905, to our efficient State Board of Health, but most of all to the secretary of the board. THE EFFECT OF INDUSTRY ON HEALTH.* There is an aged physician in one of the small towns, all his life a scientist, who has secured a modern microscope from Germany a year ago at great personal sacrifice, that he might keep No legal provision was made requiring the emabreast of the advance of medical knowledge. ployment of scientific men for the investigation, This physician is now pursuing original investi- but Dr. Charles Harrington, realizing the imgation under conditions which would infallibly portance of preventive medicine and, therefore, paralyze the ambition of the majority of young of encouraging specialization in sanitary work, men and is setting an example to be emulated saw that just as an expert may trace typhoid by all who bear the title of Doctor of Medicine fever to a polluted water supply of a workshop, in this country. The example is followed, so one versed in medicine and hygiene may trace however, and there are many who are making splendid use of the microscope in towns of the interior where one would least expect to find an instrument too commonly regarded as only fit for the laboratory. chronic lead poisoning to improper devices for the removal of lead fumes from furnaces containing kettles of molten lead. In fact, Dr. Harrington even went so far as to announce to one of his classes in hygiene in the Harvard Medical School that only graduates of medicine or those receiving degrees on Commencement Day would be eligible for the work. Were a laboratory for research provided, it would be of incalculable value to the many who to-day have no adequate place where such scientific work can be done; the commission would Moreover, no legal provision was made for the receive a powerful weapon to advance its ever- careful consideration of conditions from a comwidening sphere of action; and perhaps the mercial point of view in connection with the foundation could be laid for a school of hygiene hygienic investigation, yet one of the points which would be valuable to American as well insisted upon by the secretary of the board was as to Porto Rican physicians, which may some that no injustice should be done to employers. day contribute to the knowledge of diseases In short, an attempt has been made to establish the factory inspection work on a scientific basis. When we reflect on the real state of affairs, In order to do this, it has seemed clear to the when we ask ourselves the question, "Where State Board of Health that special pains should did ninety-nine of a hundred physicians practic-be taken to assure the employers that the work ing in the tropics receive their medical educa- is not only free from anything underhanded, but tion?" we begin to see where the difficulty lies. that it is of such a nature as to enlist their Whether a man is an American or a Spaniard he hearty co-operation. has usually studied his profession in northern climates. The diseases seen in his clinical course affecting countries beyond its shores. *Read at the regular meeting of the Monday Evening Club, Feb. 18, 1907. that is to say, conditions which are not indispensable to an industry. Among the first group of conditions are dangers which are direct and obvious in their effects upon the health of the workers: some of these dangers, are avoidable; others are to a certain extent avoidable; while others are entirely unavoidable. The subject of industrial hygiene is at once with the industry, broad and complex, and the brief time allowed for the investigation has permitted only a preliminary basis for further study and development. At the same time, a sufficient number of establishments has been examined in several industries to warrant certain definite recommendations to the legislature providing for a more efficient protection to the health of the operatives than now exists. An example of unavoidable conditions may be found in the textile industry- an industry much abused by health critics who complain of the Without entering into details it is necessary effects of textile processes upon the health and before considering our subject to define carefully welfare of the workers. At times, for instance, in just what is meant by "dangerous trades." the carding-room of a cotton mill, the cotton One of the first things which ought to be done dust, although always present to some extent, flies for the good of all is to revise the lists of the about the room like snowflakes and covers the so-called "dangerous trades." A feature strongly hair and clothes of the workers. The reason is to be condemned is the enumeration of a large that the metal-toothed cylinders become clogged number of occupations as being more than others from time to time with waste fibers and need to conducive to disease, without discriminating be cleaned. It is the cleaning that scatters the between an entire industry, the greater part of dust. Attempts have been made, with more or which may be conducted within reasonable limits less success, to obviate this objectionable feature, of safety, and the few trades which from their but until the machine manufacturers shall devise very nature are intrinsically dangerous. More- some practicable means for getting rid of the dust over, with any classification there is need of an we must not blame the employers. accompanying table of some sort to show that other causes as well as occupations have to be reckoned with. I am not saying that cotton manufacturers cannot improve present conditions; they can improve them, and they ought to be compelled to do Charts are arranged, and are frequently placed so, but we must distinguish carefully between the in the most conspicuous parts of exhibition changes which the employer cannot reasonably halls, to show by their hideous black lines the be expected to make for his employees at the death-rate from consumption of men in various present time and the changes which, regardless occupations. Do the persons responsible for such of his wishes, can be made and ought to be made. displays realize that they are producing mental It should be remembered that our best mills, pictures in the minds of the young which are with their large, well-ventilated workrooms, and immeasurably wrong and difficult to erase? Do the older mills which are under the ablest superthey not forget that overcrowded localities, such vision, are progressively attacking from a comas the slums of large cities, furnish all the con-mercial point of view the very problems which go ditions which favor a high mortality, viz., "un- hand in hand with improved hygienic conditions. sanitary dwellings, immorality, intemperance, high birth-rate, carelessness, ignorance, filth and improper and insufficient food"? The emphasis of danger, therefore, should be placed not upon the textile industry as an industry but upon those departments wherein the dangers arise. There is no question but some of the highest death-rates occur in manufacturing communities An example of the avoidable dangerous condiand that unsanitary conditions in industrial es- tions incident to an occupation was seen in a tablishments are to a certain extent responsible; large wire manufacturing establishment containbut it is undeniably true that the number of ing, among other departments, a room for temperoccupations, referring to the trade as a whole, ing wire. After the men harden the wire by which are directly accountable for ill-health and running it into the crude oil, it is passed through disease at least in the State of Massachusetts kettles of molten lead inside the tempering furare few. naces to be" tempered.' The lead is heated to This fact by no means lessens the importance the melting point and the wire is drawn through, of protecting the health of our employees in work- heated red hot. In this room there were found a shops, and of protecting the public in their daily number of tempering furnaces where the work was contact with the working people. It does, how-conducted as described. The room was uncomever, suggest that it is time to call a halt on the fortably hot and was filled with a dense blue custom of stamping with condemnation many of smoke arising from the furnaces. One employee, our industries merely because of those trades which make up the dangerous minority and because of the recognized harmful conditions which, while existing, are readily amenable to law and an effective governing body. From a sanitary point of view all industrial conditions may be classified for practical purposes into two main groups, as follows: I. Conditions which arise from the industry. who had been here for thirteen or fourteen years, showed on examination distinct evidence of chronic lead poisoning, and on questioning him it was found that four years previous he had what is known as the "wrist drop," and that he had suffered from other symptoms of lead poisoning. Three or four other cases of lead poisoning were reported as originating in this room; one employee of five years' standing had been a lumberman, robust and healthy; he now |