A Yankee doctor in paradise

by S. M. Lambert

CHAPTER XIII

HOW THE ANSWER CAME

In Fiji we started out directly for cure and prevention, an active campaign. Chris Kendrick was still with me, my gem of the first water; Malakai was a newly discovered diamond.

On my first tour I saw filthy sanitary arrangements, or none at all. By education we tried to induce the natives and oriental transplant to use ordinary cesspit latrines; our efforts met with more success after the discovery of a new internal remedy had rewarded us with public approval and made the Fijians health-conscious. From then on the pathway was cleared for all our efforts. Dr. Heiser, when he visited us in 1928, introduced the bored-hole latrine, which was the Foundation’s enthusiasm at that time. It was a twenty-five-foot hole dug with an eighteen-inch auger, which was a practical benefit to the East Indian in Fiji; but, for the native, the deep pit, covered with a polished concrete slab—which we were by then making and distributing by thousands—was by far the better sanitation.

Dr. Heiser came out again in 1934. In his An American Doctor’s Odyssey he was kind enough to report those two visits at some length. On his latter trip we made the surveys together and looked over results of our bored-hole work. I have a pleasant memory of our expeditions; how he belied his sixty-third birthday when his long legs walked me lame in Fiji, Tonga and Samoa. We argued like a pair of plumbers on a holiday; subject, Bored Latrine versus Cesspit. I contended that the deep auger-hole was all right for the delicately built Indian, but, even then, in rocky or sandy soil it was no good at all. And for Fijians it wouldn’t work. Why? In a land where the natives use palm leaves, breadfruit leaves, stones, coconut husks and hanks of wild grass for toilet purposes, a narrow tube in the ground gets stopped up in less time than it takes to bore it. Then the chap takes to the bush, as of old. It has nothing to do with science, it’s just practical mechanics, plus tradition. Our debate had this effect at least; we later modified the bored-hole latrine with a much larger hole, but retained the concrete slab, which was admired by barefoot natives for its reliable cleanliness.

******

But in 1922, as a newcomer in Fiji and with only such authority as I could get by talking myself into it, this broken jigsaw puzzle looked to me like something no mere human hands could put together. I was a health officer on a rather large scale with nothing so much as a dog license to show for it. It was pretty discouraging, at first. I was like a fireman with a leaky hose, trying to stop a blaze at one end of a building while an incendiary poured gasoline on the other. The government health authorities had a right to mourn over the Foundation’s recent attempt to kill the all-pervading parasite. Everywhere I went I saw how little the good work had accomplished. Chris Kendrick would come back from treatments in outlying districts and smile ruefully. “They’re quite a mess out there.” Like all of us, he was losing faith in chenopodium; and Chris Kendrick’s faith would stand a good deal of punishment.

Nevertheless, I was working vigorously to educate the natives in the nature of various parasites and the virtue of treatment. And I was pumping up British enthusiasm with every publicity device I could lay my hands on. As I tooted the Horn of Health they began to look upon me as Barnum’s little brother with a rich strain of Rockefeller in me somewhere.

One of my less dignified efforts along the line of health-advertising was a window display I devised for Pop Swann’s drugstore, prominent on Suva’s main street. Pop was a stanch friend of medical progress. So it didn’t take long to convince him that an attractive display of intestinal parasites would help both his business and mine. Most of his customers were Fijians and East Indians, so nothing could be more logical. “Anything in the world to push things along, my boy,” said enthusiastic Pop. Between us we set up a charming arrangement in the two windows on either side of his street door, where all who passed could wonder and admire: worms of every variety in the big gallon bottles they call “Winchesters.” Tapeworms of infinite length slithered around in alcohol; families of Necator americanus swam cozily beside a jugful of oriental Ankylostoma; there was a large bottle devoted to the fat roundworms, nearly a foot long, and to the screw-headed whipworms, and to other, less notorious wrigglers. Pop Swann rubbed his hands as we stood outside gloating over our work in the two windows that fledged his main door. “Doc,” chuckled Pop, “that ought to draw customers, if anything will!”

Then a very busy week, uphill and down dale, organizing the campaign and pushing it along. One day, going by Pop Swann’s, my way was blockaded by a semicircle of Indians and Fijians, standing at a respectful distance from the great exhibition. Out of the door burst Pop, hair on end. “Doc,” he shouted, “for the love of God take those things out of my windows. The natives are so scared they won’t pass in between those worms. You’re ruining my trade!”

So I dewormed the window and time marched on. But it wasn’t marching well for me, or in the right direction.

******

One late afternoon in February, 1922, I keeled back in my office chair and appreciated the soreness a middle-aged prize fighter must feel after he has taken the count in round one. With a sanitary squad of nine native and Indian assistants and the invaluable Chris Kendrick I had again made a round and seen the dank hopelessness of two races weakened by their own customs and by the unfriendly acts of nature. It was just as Paley had shown: rainfall flooded their shallow wells and mixed with the foulness of their latrines so that both wells and latrines had the same bacterial flora. In some districts hookworm infection ran as high as 98 per cent. This condition was not limited to primitive natives by any means; the Hindu and Moslem of ancient culture were quite as ignorant of sanitation, and more worm-laden than their dark brown brothers.

This filthy stable must be cleaned, but the baffling thing was to find the cure. Our International Health Board was sharing expenses with the Government for a three-year campaign. The question of throwing good money after bad had come up again. Officially, I should have been pro-chenopodium. Actually that drug was the first word in my Hymn of Hate. And the discouraging thing was this: despite the crucial need of hygienic improvements, an effective cure must take first place as an educational demonstration. If you destroy all the hookworms inside the human body, no more of their eggs will fall to the ground to hatch the larvae that make the worms that suck the blood.... The whole Jack-built song of consequences with a tropical setting. Sounds very simple, doesn’t it? So does astronomy.

I sat at my desk, facing facts and not liking a single one of them. Evening was coming on and I should have been home for dinner. I was too sick of myself and my work to move a muscle. Three more years of this, and where would it get us? Nowhere.

Maybe it was my guardian angel who stole up and laid a still hand over mine. Without knowing what I did or why I did it, I moved my hand across the desk and woke, blinking. I had picked up the Journal of the American Medical Association, a November 1921 issue, and an invisible finger seemed to point the page for me. And there was the title: “The Use of Carbon Tetrachloride in the Removal of Hookworm ... by Maurice C. Hall.” Hall was the man who approved my experiment down in Rabaul when I gave those injections to six cannibal prisoners. I respected him, as most of the profession did. As Senior Zoologist of the United States Bureau of Animal Industry, his researches had gone far in his own field. He didn’t talk unless he knew what he was talking about.

Here was Hall’s report in the modest gray of scientific language, revealing years of most careful observation. His tests had led him to a novel drug—carbon tetrachloride. Queer, humble thing to have fished out of the pharmacopoeia! Hitherto it had been useful only in dry-cleaning fluids and fire extinguishers. He had observed that patients under chloroform anesthesia frequently emit a number of intestinal parasites. Chloroform, then, would be a successful vermifuge were it not for its poisonous qualities. Hall made hundreds of tests down the list of Hydrocarbons until he came to chloroform’s close relation. Chloroform’s chemical initials are CHCl₃. Tetrachloride’s laboratory name is CCl₄.

Tetrachloride touched the spot Hall had been looking for. He tried it first on dogs, then on swine, horses, monkeys. He carefully gauged the dosage to 3 cc. for every 10 pounds of animal weight; later he found that O.3 cc. to every kilogram of body-weight expelled the worms in surprising quantities. After treatment he had performed postmortems on many animals and had examined internal organs which showed no pathological changes that could be traced to CCl₄. In animal experimentation it had been an unqualified success.

In animals, yes. But what of man?

The answer came like a clap of thunder out of Hall’s quietest paragraph. He had tried the stuff on himself. Audaciously he had taken a 3 cc. dose, gone to bed and wakened in the morning with no pathological symptoms. The dangerous drops he had swigged the night before had had none of the nauseous effects of chenopodium. His animal experiments had shown him that it worked as fast, as safely and more thoroughly. And here was another point in its favor: tetrachloride tried on animals seemed to have no ill effects on pregnancy. Chenopodium had always been a dangerous thing to give a woman with child. It was, at times, among the unsafe abortifacients—often effective if used up to the poison point.

The message of tetrachloride came to me like an answer to prayer. But would the dog-cure turn out to be a man-killer? Probably not. Hall had tried it on himself.

******

With a hop, skip and jump I went to the laboratory used by the Medical Officer of Health. Naturally old Carment, who presided over the collection, wouldn’t have the drug. Why should he? Yes, but there it was! A big, brown bottle with the label CCl₄. It had never been opened, of course, and how it got there nobody knows. Strange, useless things drift onto laboratory shelves.

When I went up to Dr. Montague’s office I had the brown bottle under one arm and the Medical Journal under the other. “Read that and look at this,” I said. He read the article painstakingly, then turned the bottle in his hand. “Lambert, try anything,” he sighed. That was about the way we all felt those days.

We had been trained in the empirical school. Try anything, if evidence is in its favor. Even the jungle medicine man, for all his black magic, has herbs and simples which the respectable practitioner might include in his remedies. A thousand years before Harvey demonstrated the blood’s circulation Asiatic wizards were giving chaulmoogra oil for leprosy—true, they gave it wrong, but they gave it. The Incas of Peru taught us the value of quinine for malaria; they chewed the bark. Before the Crusades, corner barbers were giving mercury to syphilitic noblemen. Up to fifty years ago the medical profession depended pretty much on the household remedies your grandmother used to choke down you; as long as they worked they saved many a fine prescription in abbreviated Latin.

The old empiricals had moved along that line. But men of the new thought, like Pasteur, like Ehrlich, had set out deliberately to fit a drug to a condition. And that was how Hall had worked.

So we were trying to cure hookworm disease with a cleaning fluid. A veterinary had recommended it. True, he was about the greatest vet in the world. I have to laugh now, remembering how we, as green young undergraduates at Syracuse Medical, used to snoot veterinaries and dentists as “hoss doctors” and “tooth yankers.” We didn’t take the trouble to remember that modern anesthesia originated in a dentist’s brain. And since we lacked the gift of prophecy, how were we to know what a horse doctor would someday do with something out of a fire extinguisher?

My mind was made up, but my heart wasn’t doing any too well when I went to the native ward and picked out four hookwormy East Indians. I wasn’t sure how these follows would behave, for Mr. Gandhi’s Civil Disobedience had become their evening prayer. However, they felt pretty sick and were ready, like Montague, to say, “Try anything.” I started them off with a stiff dose of salts.

At seven next morning my faltering hand administered to each of them 3 cc. out of the brown bottle. The minute they swallowed it I felt like a Borgia. It was too late to do anything about it, unless I gave them a quick emetic. If tetrachloride went back on me I’d be responsible for the death of a man, maybe four. Doctors have to become hardened to death, otherwise they couldn’t remain in practice. But experimental killing is a different thing. If any of these Hindus died I’d have the weight on my soul. Not only that, I’d lose my job.... Already I saw my resignation from the International Health Board being requested by cable.

I steadied myself with an argument: If the Fiji campaign failed along the old line that wouldn’t be any feather in my cap either. Well, I was deciding something on a very long chance.... My stomach went back on me, foolishly reflecting the pain of my victims. Solid food didn’t appeal, so I breakfasted on a pint of coffee, embittered with a new torment. Why hadn’t I taken tetrachloride myself, before I tried it on those Indians?[3]

Dr. Hall had taken a dose of it.

I had dosed my four Indians at seven, and time was wearing on. Tetrachloride, which is a purgative, should have acted quicker. The men were dumb and drowsy. Would this be coma? I felt their lean wrists, listened to their lean chests; pulse and respiration normal. How soon would they take a turn for the worse?

Dr. Hall had taken a dose of it.

Yes, but Hall had been in the prime of health, able to throw off toxic poisoning. These poor fellows were like dry leaves. The very thing that made treatment necessary had weakened them to the exhaustion point.... Then I thought: Even if I had drugged myself with the stuff it wouldn’t have proved much; what I was trying to find out was its actual effect on hookworm....

******

I had wandered back to my office, hoping that solitude and a cigarette might tell me what to do next.... The door burst open and Chris Kendrick tumbled in on me. His look was grave as he said, “That tetrachloride—”

“Are they dead?” I asked stiffly.

“Dead!” Chris waved his hands. “They’re all jumping out of bed, and simply spouting hookworms!”

That was how the news came to me. I had been watching them for hours while local medical officers passed their beds and made long faces which said to my fevered imagination, “See what Lambert’s done now!” Then the minute I turned my back CCl₄ had begun to work. For three days while my Indians were, as Chris exaggerated it, “fairly spouting worms,” the result was a constant wonder. Cordiality glowed in an atmosphere which had been none too warm. Doctors gathered around our hookworm count like baseball fans around the box score. The native orderlies were as excited as the rest. First day, second day, third.... I had gambled with four lives, and won. I call that Tetrachloride Experiment Number 2, since Hall swallowed the first dose; and Experiment Number 2 was a surprising success. Between them my patients had expelled 244 worms after a single dose. The following week we gave them a test treatment with chenopodium—and only got four Necators. The man I mark down as Case 1 expelled none at all. The other three needed no follow-up treatment. In three days Case 1 had shed ninety-five hookworms, and all were discharged as cured. One dose of CCl₄, mind you, had proven 99 per cent perfect.

******

Mine was the embarrassment of riches. I had worked for the Foundation too long to believe that they would approve of wholesale treatments with so new and untried a drug. If I went on with tetrachloride, as I felt I must do, the only way was to go ahead and say nothing about it.

Dr. Montague’s enthusiasm was as great as mine, but I moved cautiously at first. The next set of East Indians I tried it on was less satisfactory than the original four. It wasn’t the fault of tetrachloride, but of Gandhi; his sick disciples were so independent that they threw their specimens out of the window before we could make an accurate worm-count. We recovered enough, however, to keep Kendrick and his force of Fijian helpers pretty busy going over the thin washings spread out on tightly stretched gauze.

I look over some of the reports of those experimental days and read:—

... Almost total lack of symptoms in the group that received the purge after the drug. Not one of them was incapacitated for his regular duties ... with no after-purge there were some who had minor symptoms. Many were sleepy for several hours....

... Young Indian working in our office given 3 cc. at 7:45 A.M. ... by 10:15 gave 85 hookworms. Total for three days 101. Test treatment showed he was cured. This illustrates the rapid expulsion of worms by this drug, which we have observed generally.

The time came when I felt that the whole thing was too important to keep to myself, so I wrote a careful letter to the Foundation. The answer from 61 Broadway with its code-name “Rockfound” was cabled back so fast that it burned a streak across the Pacific: “Forbid use. We do not experiment with human life.”

I took the limp message to Dr. Montague and said, “Well, the jig’s up. I’m forbidden to play with fire extinguishers.”

Montague thought a long time. Tetrachloride was God’s gift to Fiji, he said, and he didn’t intend to give it up. He was recommending it for all the institutions under his authority.

Then I found an out. I asked, “Do you authorize me, as your subordinate, to continue its use? Would you O.K. a letter to that effect?” He said he would, and he did. After that I heard no more objections from the Foundation, whose administrators were only too glad, of course, to have the drug tried out on a large scale, as long as the Government of Fiji took the responsibility.

******

Up to the time when I grew bolder and dosed a whole large Indian school, the new treatment had been tried very quietly. Then it got too public to be kept away from the press. It was at the Dilkusha Mission that we gave this first “mass treatment”—the only practical way of administering a cure to the many. Before that it had been a matter of tedious house-to-house canvas. At Dilkusha we lined up 400 children, and I was about as jittery as I had been when I tackled the four adults at the War Memorial. But I went away smiling, a little cocky about myself. One dose of tetrachloride had removed 99 per cent of the infestation. Meanwhile in Suva Jail Dr. Kalamkar, East Indian physician, had run up a score of 94.5.

All this was news, and Suva had an editor with a keenly developed news-sense. His name was Victor Abel, and among other bold enterprises he ran a paper called the Pacific Age. A daring young chap of a good Anglo-Jewish family, he had raised mules in South Africa, made a failure of it, then come to Fiji to raise hogs, and made a failure of that too. His influential father-in-law was Sir Henry Marks, who worried a great deal about the Pacific Age.

Sir Henry had set his cap for a place on the Executive Council, and you never could tell what the incorrigible Victor would say next to stir up the Government. The town was always agog, waiting for some new outbreak in his personal correspondence column. It was a completely open forum, that column; under all sorts of fancy noms de plume citizens let each other have it, straight in the nose. Then, just to keep the pot boiling, they would change their noms de plume overnight and start thundering on the left. When Victor decided to write anything up he trimmed it artistically. For example, there was his famous account of the government yacht left in Suva harbor with her seacocks open. She gently sank, while the officers and crew were ashore seeing a football game.

In the midst of our growing campaign Victor came to me and said he was pretty sure he had hookworm. He had; and tetrachloride did its work very nicely. “Listen, Doctor,” he said, “what about this magic stuff? Where did it come from? What’s the story? Are you going to bury big news like that in Suva? Tell me about it, let me put it on the wire and I’ll have the whole world sitting up.”

By that time Fiji was certainly sitting up. Natives were clamoring for treatment. Not until the gold rush of ’32 was anything more generally talked about. I wanted Victor to have the story; I said to Victor, “You can run the story provided you keep me out of it—and don’t mention the Foundation, either. Just say that Maurice C. Hall’s treatment is being given. If that’s understood, here are the facts.”

Victor kept his word in an appropriately sensational style, proclaiming that Maurice C. Hall was curing hookworm with a thing called tetrachloride. The news thrilled the medical world, scientific men were mulling over the possibilities of a new and novel drug. How would it come out in Fiji? That was the question.

When the tidings came to Washington, friendly biologists crowded Dr. Maurice C. Hall’s office to congratulate him, and his reply was characteristic. “You say I’ve been curing hookworm in Fiji? Hell, I’ve never been near the place.”

******

In a month I had treated more cases than my predecessor had in fourteen months, and with no increased expense. Tetrachloride worked with such accuracy that there was no need of repeated doses, as with chenopodium. By the end of 1922 the Rockefeller Foundation, which had untangled the Hall-Lambert collaboration and duly forgiven my disobedience, reported 52,000 treatments by tetrachloride.

Of these 50,000 had been given in Fiji, under my supervision.

The history of public health cannot be written by the sure-cure patent-medicine man. We had our bumps, at first, but they were amazingly few. In every district where the Willis salt flotation method showed a hookworm frequency of over 60 per cent we rounded the people up and gave the treatment en masse. In regions like the dirty Rewa and Navua districts infection was particularly heavy. In one place we dosed 1,243, and came back in a month to find 1,111 villagers showing negative—about the average sample of our work as it increased to large proportions.

Primitive folk made a carnival of our coming; drums sounded and they all reached out for the wizard drops. They called it “toddy” and said it was fine because it made them drunk. Possibly it did, a little. After a child’s-size dose small boys would run around like wild dogs, tear up the flower beds in mission compounds, throw mud and have a perfectly bully time. Full-grown “marys” would caper and dance like Aunt Dinah at an old-fashioned revival; but when their big buck husbands smacked them they would come back to normal with surprising alacrity. Most of the demonstrations were merely put on; our patients usually went wild before the drug could have had time to take effect. However, tetrachloride has a mildly intoxicating reaction, especially if it is not administered with some technical care. But these demonstrations were mostly psychological—the native craving for a big joy party. The British have been more than wise in keeping alcohol away from these people.

After the first two years of wholesale treatments we had to report seven deaths. Postmortems under the observation of able physicians revealed the causes. These seven were all East Indians. One of them, it turned out, hadn’t taken tetrachloride at all; it had been chenopodium. One lad who died had a congenital malformation of the intestine, a deformity which would have prevented his living to maturity. Another was a woman who was addicted to the use of alcohol. The remainder were children heavily infected with Ascaris lumbricoides (roundworm).

When the deaths came, after forty thousand treatments, I took it pretty hard. I had gambled for success with everything I had, my job, and my professional good name. I felt as though I hadn’t a friend in the world. Then who came unexpectedly to my support? Dr. Basil Wilson, whom I had always thought of as a queer sort of Englishman with an aversion to me, if any feeling at all. Stanchly Dr. Wilson did the friendly thing; he postmortemed the bodies and developed theories as to the cause of death so sound that they stand on record today. Among his medical colleagues he became my champion. Worry was aging me years in a day until Wilson’s support renewed my youth with courage. Funny Englishman; I could have kissed his long, homely face.

Since that first setback tetrachloride has not caused one death among the thousands of Melanesians, Polynesians, East Indians and Europeans whom we treated.

The fatalities were limited to victims of alcoholism and roundworm. That was interesting; more especially in Ascaris cases. Alcohol was contra-indicated; a few drinks before or after treatment brought complications. Lingering headaches which came to many of the nondrinkers were easy to relieve with an after-dose of salts. But what about the roundworm? Why did his presence in the intestine turn tetrachloride into an active poison? I don’t think that question has been settled yet. One theory says that CCl₄, while it does not kill the Ascaris, irritates him to a point where he secretes lethal toxic juices. According to Dr. Lamson and his collaborators, poisoning with tetrachloride occurs in dogs when there is a lowered blood calcium. This chemical poverty may have something to do with it; I make the conjecture, without being able to substantiate it, that there is a relation between a large number of ascarides and a lowered blood calcium.

******

In the course of the next ten years 286,486 Pacific Islanders were treated, under my personal observation, with carbon tetrachloride and the later drug, tetrachlorethylene.

For the gifted Dr. Hall had come across with an improvement on his discovery, and he asked me to give it its first tryout when I campaigned in the wild New Hebrides in 1925. I used it extensively down there, and optimism sounded in my conservatively worded report. Its work was faster, its toxic effect less than that of his original find. There is no 100 per cent in medicine, but Hall’s new polysyllabic drug was hitting an average that was uncanny.

What a wizard he was, this pre-eminent zoologist, who was Washington’s Number One horse doctor! Every pet dog wags his tail (or should) in gratitude for his two deworming remedies. The dog’s pal, the human, is Hall’s debtor—all but the fur dealers. The price of silver fox has taken a terrific slump. Do you know why? Dr. Hall sent his tetrachlorides to the fox farms where so many hookwormy bitches and pups used to die that pelts had become a luxury for the wives of steel barons. When Hall’s treatments came to Foxville the breed picked up rapidly and its fur went to the lower department stores; so now every stenographer can have her silver fox—and on her own salary, too. Ask your furrier.

Dr. Hall is dead now. I know it’s trite to say that such men don’t really die. He has put his own spark into millions of men, women and children who would be in their graves today were it not for what he freely gave. He was an untold benefit to the human race. Most of the human race, of course, have never heard of him.

Then let’s sum up the work of tetrachloride over seventeen years since the enterprising Victor Abel first put it on the wire. Dr. Heiser, authority on public health, used to call hookworm the world’s most prevalent disease; in all Earth’s population one out of three had it, he said. Then the figures on tetrachloride (and tetrachlorethylene) treatments went up and up; 654,896 in 1924; 3,000,000 in 1936. In 1937 I attended a League of Nations conference in Java. A group of us were discussing hookworm treatments. I was pretty cocky about the 500,000 done in the Pacific; so I asked Dr. Chellapa of Ceylon how many they were doing there. Last year had been a pretty bad one, he said—they had only given 1,400,000 treatments on account of the malaria epidemic. They usually got 2,000,000 he explained. I just said, “Very fine, indeed,” in a manner I hope wasn’t patronizing. I never mentioned our figures. However, in Ceylon they are using the same old Fiji formula and dosage.

One statement may be simpler than these figures. Every year the Rockefeller Foundation used to publish a bulletin of the number of hookworm treatments. In 1938 hookworm was not even mentioned in the Foundation’s report, except for data on some still undefined parasite recently found in Egypt. The report had no general heading for ankylostomiasis. The worm which had been the source and inspiration of their world campaigns had dropped out of their ken.

My application of Hall’s discovery immediately heightened my prestige all over the Pacific. I don’t claim credit. I happened to be the man who stood at the crossroads when a wonderful sort of salvation came my way. I would have been a fool if I hadn’t seized it and carried it on. And what a lucky afternoon that was, early in 1922, when I read a little article and found a brown bottle labeled CCl₄. It gave me the courage I needed to strengthen me for a message of my own, which I knew I must work out and make clear in the hard days that were to follow.

PART TWO