THE LIBRARY
OF
THE UNIVERSITY
OF CALIFORNIA
PRESENTED BY
PROF. CHARLES A. KOFOID AND
MRS. PRUDENCE W. KOFOID
TREASURY DEPARTMENT.
Public Health and Marine-Hospital Service of the United States.
WALTER WYMAN, Surgeon-General.
HYGIENIC LABORATORY. BULLETIN No. 10.
XJ J. WOSENAU, Director.
^ebruary, 19O3.
REPORT
UPON THE
PREVALENCE AND GEOGRAPHIC" DISTRIBUTION OF HOOKWORM DISEASE
{Uncinariasis or Anchylostomiasis}
IN THE
UNITED STATES.
BY
CH. WARDELL STILES, Ph. D.
Chief of Division of Zoology.
WASHINGTON:
GOVERNMENT PRINTING OFFICE.
1903.
NOTICE TO LIBRARIANS AND BIBLIOGRAPHERS, CONCERNING THE
SERIAL PUBLICATIONS OF THIS SERVICE.
The Hygienic Laboratory was established in New York, at the Marine Hospital
on Staten Island, August, 1887. It was transferred to Washington, with quarters in
the Butler Building. June 11, 1891, and a new laboratory building, to be located in
Washington, was authorized by act of Congress, March 3, 1901.
The following bulletins (Bull. Nos. 1-7, 1900 to 1902, Hyg. Lab., U. S. Mar.-Hosp.
Serv., Wash.) have been issued:
No. 1. Preliminary notes on the viability of the Bacillus pestis. By M. J.
Rosenau.
No. 2. Formalin disinfection of baggage without apparatus. By M. J. Rosenau.
No. 3. Sulphur dioxide as a germicidal agent. By H. D. Geddirigs.
No. 4. Viability of the Bacillus pestis. By M. J. Rosenau.
No. 5. An investigation of a pathogenic microbe (B. typhi murium Danyz) applied
to the destruction of rats. By M. J. Rosenau.
No. 6. Disinfection against mosquitoes with formaldehyd arid sulphur dioxide.
By M. J. Rosenau.
No. 7. Laboratory technique: Ring test for indol, by S. B. Grubbs & Edward
Francis; Collodium sacs, by S. B. Grubbs & Edward Francis; Microphotographj
with simple apparatus, by H. B. Parker.
By act of Congress, approved July 1, 1902, the name of the "United States Marine-
Hospital Service" was changed to the "'Public Health and Marine-Hospital Service
of the United States," and three new divisions were added to the Hygienic Labora-
tory.
Since the change of name of the service the bulletins of the Hygienic Laboratory
have been continued in the same numerical order, as follows:
No. 8. Laboratory course in pathology and bacteriology. By M. J. Rosenau.
No. 9. Presence of tetanus in commercial gelatin. By John F. Anderson.
No. 10. Report upon the prevalence and geographic distribution of hookworm
disease (uncinariasis or anchylostomiasis) in the United States. By Ch. Ward ell
Stiles.
In citing these bulletins, beginning with No. 8, bibliographers and authors are
requested to adopt the following abbreviations: Bull. , Hyg. Lab., U. S. Pub.
Health & Mar.-Hosp. Serv., Wash., pp. .
MAILING LIST.
The laboratory will enter into exchange of publications with medical and scientific
organizations, societies, laboratories, journals, and authors. Its publications will also
be sent to nonpublishing societies and individuals in case sufficient reason can be
shown why such societies or individuals should receive them. All applications for
these publications should be addressed to the "Surgeon General, U. S. Public
Health and Marine-Hospital Service, Washington, D. C."
TREASURY DEPARTMENT.
Public Health and Marine-Hospital Service of the United States.
WALTER WYMAN, Surgeon-General.
HYGIENIC LABORATORY. BULLETIN No. 10.
M. J. ROSENA1LJ, Director.
February, 19O3.
REPORT
UPON THE
'REVALENCE AND GEOGRAPHIC DISTRIBUTION OF HOOKWORM DISEASE
{Uncinariasis or Anchylostomiasis)
IN THE
UNITED STATES.
BY
CH. WARDELL STILES, Ph. D.
Chief of Division of Zoology.
WASHINGTON:
GOVERNMENT PRINTING OFFICE.
1903.
ORGANIZATION OF HYGIENIC LABORATORY.
WALTER WYMAN, Surgeon- General,
U. S. Public Health and Marine-Hospital Service.
ADVISORY BOARD.
, U. S. Army; Surgeon John F. Urie, U. S. Navy; D. E. Salmon, Chief
of U. S. Bureau of Animal Industry; and Milton J. Rosenau, U. S. Public Health and
Marine-Hospital Service, ex officio.
Prof. William H. Welch, Prof. Simon Flexner, Prof. Victor C. Vaughan, Prof.
William T. Sedgwick, and Prof. Frank F. Wesbrook.
LABORATORY CORPS.
Director. P. A. Surg. Milton J. Rosenau.
Assistant Director. Asst. Surg. John F. Anderson.
Pharmacist. M. H. Watters, Ph. G.
DIVISION OF PATHOLOGY AND BACTERIOLOGY.
Chief of Division. P. A. Surg. Milton J. Rosenau.
Assistants. Asst. Surgs. John F. Anderson, Herman B. Parker, Edward Francis
Thomas B. McClintic, and Clarence W. Wille.
DIVISION OF ZOOLOGY.
Chief of Division. Oh. Wardell Stiles, Ph. D.
Assistants. Phillip E. Garrison, A. B.; Brayton H. Ransom, B. Sc., M. A.; Earle
C- Stevenson, B. Sc. ; Arthur L, Murray.
2
CONTENTS.
Page.
Summary 9
Introduction 11
Definition 11
Terminology 11
Historical review 12
Brief review of hookworms 12
Zoological position of the parasites 13
Family Strongylidse 13
Subfamily Strongylinae 14
Genus Undnaria Froelich, 1789 15
[ Undnaria Froelich, 1789, sensu stricto] 19
The New World hookworm Undnaria americana Stiles, 1902
of man 19
Life history of Undnaria americana 20
Development outside the body 20
Development inside the body 20
[Agchylostoma Dubini, 1843] 21
The Old. World hookworm Agchylostoma duodenale Dubini,
1843, or Undnaria duodenalis( Dubini, 1843) Kailliet, 1885
of man _> 21
Life history of Agchylostoma duodenale 24
Development outside the body 25
Segmentation 25
Embryo 25
Second stage 26
Development inside the body 28
Third stage (without buccal capsule) 28
Fourth stage (with provisional buccal capsule) 28
Fifth stage (with definite buccal capsule) 30
Source of infection- of uncinariasis 30
Brief review of uncinariasis 31
Brief review of uncinariasis in the United States 32
Itinerary of the trip through the Southern Atlantic States 37
District of Columbia 37
Virginia 37
Richmond and State Farm 37
North Carolina 38
Virgilina copper mine district, southern Virginia and northern North
Carolina 38
Cumnock coal mines, Chatham County 38
Sanford, Moore County 38
Itinerary of the trip through the Southern Atlantic States Continued. Page.
South Carolina 39
Camden, Camden County 39
Haile Goldmine, Lancaster County 39
Kershaw County 40
Charleston, Charleston County 40
( Georgia .- 41
Atlanta, Fulton County 41
Macon, Bibb County : 41
Milledgeville, Baldwin County 42
Fort Valley, Houston County 42
Albany, Dougherty County - 43
Willacoochee, Coffee County 43
Waycross, Ware County 44
Florida 44
Jacksonville, Duval County
Waldo, Alachua County
Ocala, Marion County
Symptomatology of uncinariasis
Light cases
Medium cases
Severe cases
General predisposing factors
Infection occurs chiefly on sandy soil
Infection occurs chiefly in rural districts
Symptoms are more severe in summer than in winter
Whites appear to be more severely affected than negroes
Occupation of patients ,
Severe cases are more common in women and children than in males over
25 years of age
Several cases are likely to occur in the same family
Objective and subjective symptoms; analysis of symptoms. _*.
Onset and incubation .
Stages of uncinariasis
Stage of purely local symptoms
Stage of simple anemia or oligocythemia (chlorotic stage)
Dropsical ^tage
Duration of uncinariasis
Length of life of the individual parasites
General external appearance
General lack of development; stunted growth. _ fc _
Skin
Wounds heal slowly
Cutaneous lesions caused by uncinariasis
Looss's theory of cutaneous infection
Bentley's theory of ground itch
Hair
Breasts
Nails
Head
Face .'
Eyelids, conjunctive ,
Eyes ,
Objective and subjective symptoms; analysis of symptoms Continued. Page.
General external appearance Continued.
Head Continued.
Nostrils ,., 66
Lips and gums 66
Teeth '. 66
Tongue 67
Neck 67
Thorax 67
Abdomen 67
' ' Potbelly " or " buttermilk belly, ' ' dropsy and tympanites 67
Extremities. 68
Genitalia . ' 68
Mucous membranes 68
Excretions and secretions 68
Urine 68
Feces 68
Consistency 68
Eeaction 68
Color ' 68
Blotting paper test 69
Microscopic examination 69
Circulatory system 69
Anemia 69
Blood 70
Cervical pulsations 72
Heart 72
Pulse 72
Temperature 72
Respiratory system 72
Nostrils 72
Respiration .*. 72
Muscular system 73
Emaciation 73
Great physical weakness 73
Digestive system 74
Lips, gums, teeth, tongue (see p. 66) 74
Nausea 74
Appetite 74
Perverted appetite, ' ' dirt-eating " 74
Pain in " stomach; " indigestion 76
Constipation and diarrhea 77
Feces 77
Nervous system 77
Eyes 77
Ears 77
Mental lassitude, headache, dizziness, arid nervousness 77
Patellar reflex t 78
Genital system 78
External genitalia, sexual function, menstruation, sterility. . 78
Tendency to abortion 79
Prevalence of uncinariasis in the United States . . 79
6
Objective and subjective symptoms; analysis of symptoms Continued. Page.
Clinical diagnosis of hookworm disease 80
Blotting paper test with feces 81
Microscopic examination of feces 85
Gross examination of feces 86
Treatment of hookworm disease 86
Anthelminthic treatment 86
Thymol 86
Male fern 89
Calomel 89
General treatment 89
Prognosis 89
Lethality of hookworm disease 90
Post-mortem appearances 91
Prevention of hookworm disease 93
Adult worms in the intestine; treatment 93
Eggs in the feces; control and destruction 93
The infecting (encysted) stage of the larva 94
Disinfecting premises 94
Drinking water 95
Clean hands 95
Wearing shoes 95
Common interpretation of hookworm disease 96
Economic importance of hookworm disease 96
Geographic distribution and abstracts of cases found in the United States 98
Bibliography Ill
Index to zoological names 117
Index to authorities cited.. 119
LIST OF ILLUSTRATIONS.
Page.
FIG. 1. Caudal bursa of a male strongyle ((Esophagostoma dentatum] to serve
as diagram for the family 13
2-9. New World hookworm ( Uncinaria americana) .
2. New World male hookworm 18
3. New World female hookworm 18
4. The same enlarged to show the position of the anus and vulva 18
5. Dorsal view of anterior end of New World hookworm 18
6. Lateral view of anterior end of New World hookworm 18
7. Lateral view of caudal bursa of New World male hookworm 18
8. Caudal end of New World male hookworm 19
9. Four eggs of New World hookworm 20
10-41. Old World hookworm (Agchylostoma duodenale).
10. Dorsal view of anterior end of Old World hookworm 22
11. Old World male hookworm 22
12. Old World female hookworm 22
13. The same (diagrammatic) enlarged to show the position of the anus
and vulva 22
14. Semidiagrammatic figure of caudal bursa of same 22
15. Lateral view of Old World male hookworm enlarged to show the
anatomy 23
16. Eggs of Old World hookworm 24
17-29. Embryology of Old World hookworm. 24
30-31. Larvse at the end of the second stage (encysted larvae) 25
32. A young hookworm of man, without buccal capsule, four days after
infection 26
33. Anterior end of larval hookworm during formation of provisional
buccal capsule 26
34. Head of larval hookworm before entering the fourth stage, five davs
after infection 26
35. Young hookworm in fourth stage, with provisional buccal capsule 27
36. Provisional buccal capsule (fourth stage) of larval hookworm, about
nine days after infection 27
37. Young male hookworm, about nine days after infection 27
38-39. Development of definite buccal capsule 28
40-41. Male and female hookworms before the fourth casting of skin, fourteen
to fifteen days after infection 29
42. A severe case of hookworm disease observed in Florida 46
43-85. Eggs and embryos of other parasitic worms.
43. Egg of common eel worm or ascaris (Ascaris lumbricoides) of man 82
44. The same, optical section, seen with median focus 82
45-54. Embryology of common ascaris of man after the egg is discharged in
the feces 82
55. Embryo of the common ascaris of man, in its eggshell 82
8
Page.
FIG. 56. Free embryo of common ascaris of man, casting its skin 82
57-64. Embryology of the common pin worm (Oxyuris vermicularis] of man,
while egg is still in the female worm 82
65. Embryo of the common pinworm of man, in the eggshell, as found in
the fresh feces 82
66. Full-grown embryo of the common pinworm of man, escaped from its
shell 82
67-70. Egg of common whipworm (Trichuris trichiura) of man, showing
changes undergone while still in the female worm; fig. 69 is the stage
found in fresh feces 82
71-73. Later stages of development of an allied whipworm (Trichuris affinis)
of sheep and cattle, showing changes after the egg escapes in the
feces 82
74. Isolated embryo of Trichuris affinis 82
75. Egg of Cochin-China diarrhea worm (Strongyloides stercoralis) 83
76. Rhabditiform embryo of same 83
77. Filariform larva of same 83
78. Egg of common liver fluke (Fasciola hepatica) examined shortly after it
was taken from the liver of a sheep. This is the same stage found
in human feces 84
79. Egg of common liver fluke containing a ciliated embryo (miracidium)
ready to hatch , 84
80. Embryo of the common liver fluke boring into a snail 84
81. Egg of lancet fluke (Dicroccelium lanceatum) with contained embryo.. 84
82. Egg of human-blood fluke (Schistosoma hsematobium) with contained
embryo, passed in the urine or in the feces 84
83. Egg of beef-measle tapeworm (Tsenia saginata), with thick eggshell
(embryophore), containing the six-hooked embryo (onchosphere) . . 84
84. Eggs of pork-measle tapeworm (Tsenia solium): a, with primitive
vitelline membrane; b, without primitive vitelline membrane 84
85. Egg of the dwarf tapeworm (Hymenolepis nana) of man 85
86. Spraying with burning oil , 94
SUMMARY
Convinced from theoretical deductions that hookworm disease (uncinariasis) must
be more or less common in the South, a trip was made from Washington, D. C., to
Ocala, Fla., stopping at penitentiaries, mines, farms, asylums, schools, and factories,
and the fact was established that the chief anemia of the Southern rural sand dis-
tricts is due to uncinariasis, while clay districts and cities are not favorable to the
development of this disease.
In the Old World, hookworm disease was probably known to the Egyptians nearly
three thousand five hundred years ago, but its cause was not understood until about
the middle of the nineteenth century, when it was shown to be due to an intestinal
parasite, Agchylostoma duodenale. Until 1893 no authentic cases of this disease were
recognized as such in the United States, but between 1893 and 1902 about 35 cases
were diagnosed. In 1902 it was shown that a distinct hookworm, Uncinaria ameri-
cana, infests man in this country, and this indicated very strongly that the disease
must be present although not generally recognized. It is now established that in
addition to the few cases of Old World hookworm disease imported into the United
States we have in the South an endemic uncinariasis due to a distinct cause, Uncina-
ria americana. This disease has been known for years in the South and can be traced
in medical writings as far back as 1808, but its nature was not understood. Some
cases have been confused with malaria, others have been attributed to dirt-eating.
The hookworms are about half an inch long. They live in the small intestine,
where they suck blood, produce minute hemorrhages, and in all probability also
produce a substance which acts as a poison. They lay eggs which can not develop
to maturity in the intestine. These ova escape with the feces and hatch in about
twenty-four hours; the young worm sheds its skin twice and then is ready to infect
man. Infection takes place through the mouth, either by the hands soiled with
larva? or by infected food. Infection through the drinking water may possibly
occur. Finally, the larvse may enter the body through the skin and eventually
reach the small intestine.
Patients may be divided into light cases, in which the symptoms are very obscure;
medium cases, in which the anemia is more or less marked, and severe cases, repre-
sented by the dwarfed, edematous, anemic dirt-eater. Infection occurs chiefly in
rural sand districts. Above the frost line the symptoms are more severe in summer
than in winter, and whites appear to be more severely affected than negroes. Per-
sons who come in contact with damp earth are more commonly infected than others,
so that the disease is found chiefly among farmers, miners, and brickmakers. Severe
cases are more common in women and children than in men over 25 years of age.
Uncinariasis is a disease which occurs in groups of cases, and if one case is found in
a family the chances are that other members of the same family are infected.
The testimony of patients severely infected is unreliable. Recalling that any one
or more symptoms may be absent or subject to variation, it may be noted that the
period of incubation (at least before the malady can be diagnosed by finding the
eggs) is from four to ten weeks. Stages are not necessarily distinctly defined, but are
described as (1) stage of purely local symptoms, corresponding to the light cases;
(2) stage of simple anemia, corresponding to the medium cases; and (3) dropsical
stage, corresponding more or less to the severe cases. The duration of the disease
after isolation from the source of infection has been traced for six years and seven
9
10
months; how much longer infection will last is not established. If a patient is sub-
ject to cumulative infection, the disease may last five, ten, or even fifteen years, and
in case of light infection perhaps longer.
External appearance. In extreme cases there is a general lack of development;
skin waxy white to yellow or tan; hair is found on the head, but is more or less
absent from the body; breasts are undeveloped; nails white; external genitalia more
or less rudimentary; face anxious, may be bloated; conjunctive pale; eyes more
or less dry, pupil dilates readily; membranes pale according to the anemia; teeth
often irregular; tongue frequently marked with purple or brown spots; cervical pul-
sations prominent; thorax emaciated; heart beats often visible; abdomen frequently
with "potbelly;" extremities emaciated, frequently edematous, and with wounds
or ulcers of long standing.
Urine 1010 to 1015; in advanced cases albumin without casts; acid or alkaline.
Feces reddish brown, contain eggs, and may contain blood.
Circulatory system. Anemia pronounced, according to degree and duration of infec-
tion; blood watery, with decreased red blood corpuscles and with eosinophilia;
"heart disease" very commonly complained of; hemic murmurs present; pulse 80
to 132 per minute.
Temperature. Subnormal, normal, or to 101 or 102 F.
Respiratory system. Breathing may be difficult, slow, or increased to as high as 30.
Muscular system. Emaciation and great physical weakness.
Digestive system. Appetite poor to ravenous; abnormal appetite often developed
for pickles, lemons, salt, coffee, sand, clay, etc.; pain in epigastrium; constipation or
diarrhea.
Nervous system. Headache, dizziness, nervousness, mental lassitude, and stupidity.
Genital system. Menstruation irregular or absent; if present, it occurs chiefly in
winter; there is a marked tendency to abortion.
Diagnosis. The safest plan is to make a microscopic examination of the feces to
find the eggs; or, if feces are placed on white blotting paper, a blood-like stain will
be noticed.
Treatment. Thymol, or male fern (or ? calomel); iron, and good food.
Prognosis. Good, if patient is not too far gone at time of treatment.
Lethality. Not yet determined.
Prevention. Treat all cases found and dispose of feces.
Economically, uncinariasis is very important. It keeps children from school,
decreases capacity for both physical and mental labor, and -is one of the most
important factors in determining the present condition of the poorer whites of the
sand and pine districts of the South.
The disease is carried from the farms to the cotton mills by the mill hands, but
does not spread much in the mills; nevertheless, it causes a considerable amount of
anemia among the operatives.
REPORT UPON THE PREYALENCE AND GEOGRAPHIC
DISTRIBUTION OF HOOKWORM DISEASE (UNCINARIA-
SIS OR ANCHYLOSTOMIASIS) IN THE UNITED STATES.
By CH. WARDELL STILES, Ph. D.,
Chief of Division of Zoology, Hygienic Laboratory, U. S. Public Health and Marine-
Hospital Service.
INTRODUCTION.
Thoroughly convinced from theoretical zoologic considerations,
especially of a faunistic nature, that uncinariasis must be a more or
less common disease in the Southern portion of the United States,
I requested instructions from Surgeon -General Wyman to study
the subject in a field investigation. The desired authorization was
received and the results of the work are contained in this paper.
DEFINITION.
Uncinariasis is a specific zooparasitic disease found especially in
tropical and subtropical sand areas, and caused by hookworms (genus
Uncinaria) which inhabit the small intestine. Its chief symptoms
are: Anemia, with the circulatory symptoms found in all extreme
anemias, namely, dizziness, palpitation, hemic murmurs; great weak-
ness, in some cases with considerable emaciation ; colicky pains in the
abdomen; perverted appetite, such as "dirt-eating;" constipation or
diarrhea, stools sometimes brownish or bloody; nausea; edema. The
only positive diagnosis is by finding the parasite or its eggs in the
stools. It may affect any class of patients, but is more frequent in
persons whose daily life brings them in contact with damp earth
(children, farmers, miners, brickmakers, excavators, etc.).
TERMINOLOGY.
The disease now under discussion is known by*a number of different
names, but uncinariasis" should be adopted as the more correct tech-
nical designation. Among the names frequently applied to it, the
Looss (1902) has recently attempted to suppress the term "uncinariasis" in
favor of anchylostomiasis, his view being that the genus Agchylostoma is distinct
from Uncinaria. His suggestion does not help matters much at present. Even if
the zoological genera are recognized as distinct, uncinariasis would still exist in man,
while among animals it would be still more common than anchylostomiasie. Further,
the two genera would probably have to be united in a subfamily, which could then
be called "Uncmariinse," and uncinariasis could then signify any infection of any
11
12
following may be mentioned in particular: Anchylostomiasis, ankylos-
tomiasis, brickmakers' anemia, Egyptian chlorosis, miners' anemia,
miners' cachexia, tunnel anemia, St. Gothard tunnel disease, tropical
chlorosis, hookworm disease, and tunnel disease. (See also pp. 31, 32,
96.)
HISTORICAL REYIEW.
In order to understand the exact status of the subject of uncinari-
asis, it will be well to take a brief historical review of hookworms in
general, hookworm disease in general, and hookworm disease in the
United States.
BRIEF REVIEW OF HOOKWORMS.
It is quite probable that the ancient Egyptians, nearly thirty -live
hundred years ago, were acquainted with the parasites which we now
call hookworms. From a zoological Standpoint, however, the first
hookworm known to science was a parasite in the intestine of the
common badger (Meles taxus) of Europe, described by Gceze, a Ger-
man clergyman, in 1782. Gceze called the parasite "der Haarrund-
wurm" (the hair round worm), and gave to it the Latin name Ascaris
criniformis. Although he placed this species in the same genus with
the ordinary eelworm, Ascaris lumbricoides, he intimated that it rep-
resented a distinct genus. One of the anatomical characters which
Goaze noticed was a membranous expansion on the tail of the male,
and in this he saw two finger- or ray -like structures which he inter-
preted as "hooks" (see caudal rays in figs. 1, 15).
In 1789 Frcelich found a similar worm in the common fox (Canis
vulpes or Vulpes vulpes) of Europe. He noticed the same mem-
branous expansion and "two hooks with many points" on the end of
the tail. On account of this character he adopted the vernacular
name "Haakenwurm" (hookworm), and proposed the generic name
Uncinaria for the new genus which he established.
It is now known that the membranous expansion is the caudal
bursa, found in all members of the family Strongylidse, while the
so-called "hooks" represent the "rays" or "ribs" which support the
bursa (see fig. 1). In the early part of the nineteenth century several
other species of hookworms were described as parasitic in various
animals, and they were united generically with the "colic worms"
(strongyles) of horses.
animal with any member of this subfamily. In case the term "anchylostomiasis "
is adopted, which of the many spellings should be recognized? Adopting uncin-
ariasis relieves us of the necessity of discussing that point, and further gives to the
name of the disease the same orthography in several different languages. The case
at hand gives rise to the question whether it is not inadvisable to name diseases
after the zoological names of the parasites, at least during the transitional stage of
zoological nomenclature. As a matter of fact it is the function of the medical pro-
fession, not that of the zoological, to determine what names should be used to desig-
nate diseases, but at the present moment, medical terminology is subjective.
13
FIG. 1. Caudal bursa of a male strongyle
( (Esophagostoma dentatum), to serve as
diagram for the family: ?;. r., ventral
rays; v. 1. r., yentro-lateral rays; I. r., lat-
eral rays; d. I. r., dorso-lateral rays; d. r.,
dorsal rays. X 93. (After Schneider,
1866, p. 130.)
In 1843 Dubini, of Milan, Italy, described a hookworm as parasitic
in man. Besides the caudal "hooks" (i. e., the "rays") of the male,
Dubinins parasite presented four hooks in the mouth. It presented
further an anatomical character which is common to all hookworms,
namely, the Ventral surface of the an-
terior end grows more rapidly than the
dorsal surface, so that the oral end is
bent backward like a "hook," and the
mouth thus occupies a dorsal position.
Thus it is seen that the original char-
acter which led to the vernacular name
"hookworm" was a misinterpretation;
the second character of "hooks" (name-
ly, in the mouth), which has been pop-
ularly but erroneously interpreted as
responsible for the vernacular name
"hookworm," is not present in all spe-
cies; the hooklike curvature of the head
is usually but not always distinct. I
propose, however, to retain the word "hookworm" as a vernacular name.
It is not apparent that Dubini knew that Frcelich had proposed the
genus Uncinaria, and it is probably on this account that he proposed a
new genus Agchylostoma by name to contain the parasite (Agchylo-
stoma duodenale) which he had found in man.
For years it was supposed that this was the only species of hookworm
found in man, but in May, 1902, I showed that in America we have a
distinct species, which I named Uncinaria americana.
ZOOLOGICAL POSITION OP THE PARASITES.
The parasites which cause uncinariasis are worms belonging to the
nematode family Strongylidse.
Family STRONGYLID.E.
FAMILY DIAGNOSIS. Nematoda: With body elongate, cylindrical, rarely filiform.
Mouth is probably always provided with six papillae, of which the four submedian
are generally salient in form of nodules or conical points. In some cases the mouth is
in the axis of the body; in others it is turned dorsally or ventrally, and occasionally
provided with a chitinous armature. Esophagus more or less swollen in posterior
portion, but without forming in adults a distinct esophageal bulb. Male provided
with a caudal bursa, open or closed, entire or divided, and with one or two spicules.
Female with one or two ovaries; vulva anterior or posterior of equatorial plane, in
some cases near the anus. Eggs deposited during segmentation, in some cases
containing embryo.
TYPE GENUS. Strongylus O. F. Mueller.
The sexes are separate and the digestive tract is complete. Charac-
teristic for the family is the presence, on the tail of the male, of an
umbrella-like structure known as the caudal or "copulatory bursa,"
14
supported by a number of finger-like "rays." which may be compared
to the ribs of an umbrella. In coitu, the male clasps the body of the
female by means of this bursa.
This family is divided into subfamilies, according to the presence of
certain anatomical characters. The parasites of uncinariasis are now
classified in the subfamily Strongylinse, a which, as its former name,
Sclerostominse, indicated, is characterized by the presence of a hard
chitinous "buccal capsule."
Subfamily STRONG- YLI^T.^:.
SUBFAMILY DIAGNOSIS. Strongylidse: Meromyaria; mouth with mtore or less com-
plete chitinous armature. Male with two equal spicules; caudal bursa with rays,
the dorsomedian and dorsolateral being united in a common base. Female with
two ovaries, except in Ollulanus.
TYPE GENUS. Strongylus Mueller.
The subfamily Strongylinse is in turn divided into a number or
genera, of which we may mention here the following:
Strongylus [Sclerostoma]; the sclerostomes, including the colic worms
of horses and the kidney worms of hogs (but not the kidney worms of
dogs and man);
Syngamus, including the gape worms of chickens; and
Uncinaria, the hookworms, including the parasite of uncinariasis.
It seems very probable that hookworms will have to be divided into
several different genera, for which a new subfamily will perhaps be
recognized, but it is not quite clear at present just what genera will
be admitted. Undoubtedly Uncinaria Froelich, 1789, must be adopted
for one, and in this will probably be placed worms like Uncinaria
stenocephala, possessing ventral lips but not ventral recurved teeth.
It is quite possible that a second genus (Monodontus Molin, 1861, or
Bunostomum Railliet, 1900) will be recognized for certain other
forms, with buccal lips and with the prominent dorsomedian buccal
tooth, as was proposed by Molin; probably the new American hook-
worm will be placed in this genus. Hookworms with the ventral
recurved buccal teeth, as seen in Uncinaria duodenalis and TJncinaria
canina will probably be separated into a distinct genus, for which
Dubini's name Agchylostoma will be available. To satisfactorily
determine the points at issue will require further anatomical study of
a number of different species. For the purpose of this paper it will
be sufficient to call attention to these probable changes.
From a study of the history of the nematode genera, it is very clear that there
will have to be a general revision of the technical names of this group. The original
Strongylus, for instance, was a sclerostome, hence the names Sclerostoma and Sclerosto-
minse will have to fall into synonymy. It i$ probable that Metastrongylus will be the
correct name for the lung strongyles. Strongylus contorlus becomes Hsemonchm
contortus. As soon as certain remaining points of this nature are decided, Hassall
and I will issue a list of nematode genera, together with their type species.
15
Genus UNCINARIA" Froelich, 1789.
GENERIC DIAGNOSIS. Strongylinse: With anterior extremity curved dorsally; mouth
round to oval, opening oblique, limited by a transparent border and followed by a
chitinous buccal capsule; the dorsal portion of the capsule is shorter than the ventral,
and is supported by a conical structure, the point of which sometimes extends into
the cavity; at the base of the buccal capsule are found two ventral teeth; toward
the inner free border the ventral wall bears on each side of the median line chitin-
ous structures, lips ( Uncinaria) or teeth, often recurved in shape of hooks (Agchylo-
stoma} ; the inner dorsal wall may also bear lips or teeth. Oviparous, eggs with thin,
transparent shell.
TYPE SPECIES. Uncinaria vulpis b Froelich, 1789.
SYNONYMY, WITH ORIGINAL PLACE OF PUBLICATION.
1789: Uncinaria FRO3LiCH<Der Naturforscher, Halle, v. 24, pp. 130-139; type, Unci-
naria vulpis Froelich, 1789.
1799: Undaria FiscHER<Arch. f. d. Physiol., Halle, v. 3, p. 99. [Apparently a
misprint for Uncinaria. ]
1843: Agchylostoma DuBiNi<Annal. univers. di medic.. Milano, v. 106, aprile, pp.
5-13; type, Agchylostoma duodenale Dubini, 1843.
1845: Ancylostoma CREPLiN<Archiv f. Naturg., Berlin, 11. J., v. 1, p. 325; for Agchy-
lostoma Dubini, 1843.
1845: Dochmius DUJARDIN, Histoire naturelle d. helminthes, pp. 267, 275-279; type,
Uncinaria vulpis Froelich, 1789.
1845: Docmius DUJARDIN, ibidem, p. 114. [Misprint for Dochmius.']
(1846): Anchylostoma DELLE CmAJE<Rendicon. dell'Accad. delle Sci. Napoli, v. 5,
p. 339. [Not verified.]
1850: Anchylostoma DUBINI, Entozoografia umana, pp. 102-112; for Agchylostoma
Dubini, 1843.
1851: Ancylostomum DIESING, Systema helminthum, v. 2, p. 82; for Agchylostoma
Dubini, 1843.
1851: Anchylostomum DIESING, Systema helminthum, v. 2, pp. 321-322; for Agchy-
lostoma Dubini, 1843.
1861: Monodontus MOLIN (not Monodonta Lamarck, 1799), II sottordine degli acrofalli
<Mem. r. 1st. ven. di sc., lett. ed arti, Venezia, v. 9, pp. 435, 463-470; type,
M. semicircularis Molin, 1861.
1861: Doohmius MoLiN<Ibidem, p. 471. [Misprint for Dochmius.]
1862: Dac/wims<Veterinarian, Lond. (416), v. 35, 4. s. (92), v. 8, Aug., pp. 549-556.
[Misprint for Dochmius. ~\
1879: Anchilostoma BozzoLO<Osservatore, Torino, v. 15 (24), 17 giugno, pp. 369-370;
for Agchylostoma Dubini, 1843.
1895: Ankylostomum 8TossiCH<Boll. Soc. Adriatica di sc. nat. in Trieste, v. 16, pp.
21-25; for Agchylostoma Dubini, 1843.
18 ?: " A nkylostoma Dubini" of various authors; for Agchylostoma Dubini, 1843.
1897: Anchylostamum MCEHLAU< Buffalo M. J., v. 36 (8), Mar., p. 573. [Misprint for
Anchylostomum.]
1902: Dohmius Looss<Centrabl. f. Bakteriol., Parasitenk. [etc.], Jena, 1 Abt., v. 31
(9), 5. Apr., Originale, p. 424. [Misprint for Dochmius.]
1902: Unicinaria VON LiNSTOw<Zool. Centralbl., Leipz., v. 9 (24-25), 16. Dec., p. 778.
[Misprint for Uncinaria. ]
&This species is probably identical with Uncinaria melis Froelich, 1789; Ascariv
criniformis Goeze, 1782, and with Uncinaria stenocephala (Railliet, 1884).
16
The anatomical character which distinguishes the genus Uncinaria
is the dorsal curvature of the anterior extremity of the body, due to
the shortness of the dorsal wall of the buccal capsule and resulting in
bringing the mouth into a dorsal instead of a terminal or a ventral
position.
In many medical writings this genus is named Anchylost-oma, a word
which is spelled in at least nine different ways, and the disease is
spoken of as anchylostomiasis. This nomenclature and terminology
are due to the fact that when the hookworm ( Uncinaria duodenalis) of
man was first described, in 1843, it was supposed to represent a new
genus (Agchylostomd). As a matter of fact, however, it is generally
acknowledged to be congeneric with a worm described in 1789 as
Uncinaria. By the international "law of priority," 1 ' therefore, the
names Agchylostoma, Anchylostoma, etc. , fall into synonymy until it
can be shown that the two species are not congeneric. (See p. 14.)
In explanation to physicians it may be here stated that zoologists
are obliged to deal with hundreds of thousands of technical names,
and on this account they have been forced to adopt very rigid rules
governing their use. Our most important rule is the "law of prior-
ity,"' which to us is as essential as is the "code of ethics" to the
physician.
The genus Uncinaria contains blood-sucking worms of the worst
type. They are usually not over an inch in length nor thicker than
an ordinary hatpin. They are provided with a heavy armature of
sharp teeth, by means of which they pierce the intestinal mucosa of
their host. They have also an unusually strong muscular esophagus,
which serves as a pump during the act of sucking blood. An important
point, from the medical aspect of the parasites, is that they do not
remain fastened to one spot in the bowels, but suck first at one spot
and then at another. Thus the patient loses blood directly to the
parasites, and also, by numerous minute hemorrhages, into the intes-
tine. It is probably this latter factor which occasionally gives to the
stools of patients that peculiar reddish-brown tinge, and also their
occasional bloody appearance.
The injury to the intestinal wall does not stop with the bite. The
wound forms an excellent point of attack for bacteria, and the intes-
tinal wall becomes thickened, thus losing, to a greater or lesser degree,
the ability properly to perform its function. Not only does the patient
lose blood, but his power of assimilation is impaired, and the supply
of blood-forming material is thus in part cut off. Some authors also
claim that the parasites produce a poison which acts upon the system,
a view which is very strongly supported by certain clinical facts.
It was stated above that hookworms are found in various animals.
Now, the general rule may be laid down that where these worms are
present trouble uia} r be expected.
17
Uncinaria americana and Agchylostoma duodenale cause in man the
disease variously known as uncinariasis, uncinariosis, anchylostomiasis,
tunnel disease, miners' anemia, brickmakers' anemia, mountain ane-
mia, etc.
Agchyloxtoma caninum '[Uncinaria canina a \ causes a similar disease
in dogs, resulting, in some parts of the country, in a death rate of
from 25 to 40 per cent of the pups born. Uncinariasis in dogs is
exceedingly common in Washington, D. C. "Typhoid" in cats is
attributed to this parasite.
Instructors in medical colleges who wish to demonstrate hookworms
and their eggs to the students will find A. caninum of dogs an excel-
lent substitute for Agchylostoma duodenale of man in case the latter
species can not be obtained.
Uncinaria stenocephala occures in dogs, foxes, and allied animals,
and is causing considerable trouble in the blue fox ( Vulpes lagopus)
industry.
Uncinaria trigonocepJiala b is found in sheep and produces a serious
anemia. This parasite has been met in Victoria and Calhoun counties,
Tex., where, in conjunction with the twisted wireworm (Hsem,onchus
contort ''us c ), it has caused the death of from 25 to 50 per cent of certain
flocks.
Uncinaria radiata d is found in cattle, producing trouble just below
the stomach. The writer has collected this parasite in Dewitt,
Gonzales, Victoria, and Calhoun counties, Texas, and has seen speci-
mens from Florida collected by Dr. C. F. Dawson.
Uncinaria Lucasi was found several years ago in the seal pups of
Alaska by Mr. Lucas, after whom the worm has been named. It is
responsible for about 17 per cent of the deaths of the pups.
Still other species of hookworms are reported for other animals.
None of the species from animals mentioned above is known to affect
man, nor has either Uncinaria americana or Agchylostoma duodenale
of man been satisfactorily demonstrated to occur normally in other
hosts than man.
This is Uncinaria canina (Ercolani 1859) Railliet, 1900, a parasite of canines and
felines, which is usually known as Uncinaria trigonocephala (Rudolphi, 1809) Railliet,
1885 [not Uncinaria trigonocephala (Rudolphi, 1809) Railliet, 1900]. If Uncinaria
and Agchylostoma are recognized as distinct, U. canina should be placed in the same
genus as U. duodenalis. I have not yet tested the correctness of the specific name
canina for this form, but it is here accepted on authority of Railliet.
& This is Uncinaria trigonocephala (Rudolphi, 1809) Railliet, 1900 [not "U. trigono-
cephala Rudolphi, 1809)" Railliet, 1885]. Both Railliet and I have recently exam-
ined Rudolphi' s original material, and it is unquestionably identical with U. cernua
(Creplin, 1829) of sheep. This species is closely related to U. americana.
c Strongylns contortus Rudolphi.
d Bunostomum phlebotomum Railliet.
19558 No. 1003 2
18
FIG. 2. New World male hookworm ( Uncinaria americana). Natural size. (After Stiles, 1902b, p. 190,
FIG. 3. New World female hookworm ( Uncinaria americana}. Natural size. (After Stiles, 1902b, p.
FIG. 4. The same, enlarged to show the position of the anus (a) and the vulva (v). After Stiles, 1902b,
FIG. 5. Dorsal view of anterior end of New World hookworm ( Uncinaria americana): b. c., buccal
cavity; c.p., cervical papillae; d. m. t., dorsal median tooth, projecting prominently into the buccal
cavity; d. sm. I., small dorsal semilunar lip; e., esophagus; m. in., margin of mouth, the prominent
oval opening seen upon high focus; p. p., papillae; v. sm. I., large ventral semilunar lips homologous
with the ventral hooks of A. duodenale. Greatly enlarged. (After 'Stiles, 1902b, p. 190, fig. 123.)
FIG. 6. Lateral view of anterior end of New World hookworm ( Uncinaria americana): b. c., buccal cav-
ity; d.m.t., dorsal median tooth, projecting prominently into buccal cavity ; e., esophagus; m.m., mar-
FIG
showing the arrangement of the rays. Note the short dorsal lobe. Greatly enlarged. (After
Stiles, 1902b. p. 190, fig. 125.)
Fm. 8. The caudal end of the New World male hookworm (Uncinaria americana). The bursa is
spread out to show the arrangement of the rays. Note the short dorsal lobe which is subdivided,
forming two lobes; note also the indistinct ventral lobe connecting the two lateral lobes. The
dorsal lobe is thrown back over the body. Greatly enlarged. (After Stiles, 1902b, p. 191, fig. 126.)
[UNCINARIA Frcelich, 1789, sensu stricto].
is. Unqinaria s. 1. with buccal lips.
TYPE SPECIES. Uncinaria vulpis Frcelich.
The New World hookworm UNCINARIA AMERICANA" Stiles, 1902 of man.
(Figures 2 to 9.)
'' SPECIFIC DIAGNOSIS. Uncinaria: Body cylindrical, somewhat attenuated ante-
riorly. Buccal capsule with a dorsal pair of prominent semilunar plates or lips,
similar to U. stenocephala, and a ventral pair of slightly developed lips of the same
nature; dorsal conical median tooth projects prominently into the buccal cavity,
similar to Monodontus. Male, 7 to 9 mm. long; caudal bursa with short dorso-median
lobe, which often appears as if it were divided into two lobes, and with prominent
lateral lobes united ventrally by an indistinct ventral lobe; for rays, see figures
7-8; common base of dorsal and dorso-lateral rays very short; dorsal ray
divided to its base, its two branches being prominently divergent and their tips
being bipartite; spicules long and slender. Female, 9 to 11 mm. long; vulva in
anterior half of body, but near equator. Eggs, ellipsoid, 64 to 76 jn long by 36 to
40 yu broad, in some cases partially segmented in utero, in other (rare) cases con-
taining a fully developed embryo when oviposited.
HABITAT. Small intestine of man (Homo sapiens) in America (determined to date,
for Virginia, North and South Carolina, Georgia, Florida, Alabama, Texas, Porto
Rico, Cuba, and Brazil) .
TYPE SPECIMENS. No. 3310, B. A. I., U. S. Dept. Agric.
a SYNONYMY WITH ORIGINAL PLACE OF PUBLICATION.
1902: Uncinaria americana STILES <Arn. Med., Phila., v. 3 (19), May 10, pp. 777-778.
1902: Unicinaria americana (Stiles) VON LINSTOW <Zool. Centralbl., Leipz., v. 9
(24-25), 16. Dec., p. 778. [Misprint.]
20
LIFE HISTORY OF UNCINARIA AMERICANA.
The life history of the American hookworm has not yet been deter-
mined in detail, but there is no reason for assuming that it will differ
radically from that of Agcliylostoma duodenale (see p. 24.)
In my first description of the worm I stated that the egg in the
uterus may occasionally contain an embryo. Since making this obser-
vation on the females sent to me by Dr. Allen J. Smith I have exam-
ined hundreds of fresh eggs, but have not found any containing
developed embryos. The question may
therefore legitimately arise whether
the females originally examined were
not exposed to the air for some time
before they were preserved, thus mak-
ing the development of the eggs pos-
sible. If the embryo does develop in
the uterus, as indicated by some of Dr.
Allen J. Smith's material, such an oc-
currence is undoubtedly rare.
DEVELOPMENT OUTSIDE THE BODY.
Segmentation. In feces exposed to a
September, October, or earty November
temperature of the Carolinas, Georgia,
and Florida, the embryo develops in
the egg (fig. 9) in about one day's time.
In some instances the embryo develops
in less than 24: hours. It is a com-
mon occurrence to find feces 24 hours
old containing free embryos.
The conditions under which the trip was made were not favorable
to exact observation in regard to temperature, moisture, etc. It was,
however, possible to find worms in their first ecdysis about 2 to 3 days
after hatching, and worms in the second ecd^^sis about 7 to 9 days
after hatching. These observations were made under most unfavor-
able circumstances, when careful measurements, drawings, etc., were
excluded, hence they should be repeated.
DEVELOPMENT INSIDE THE BODY.
Experimental infections during the trip were, of course, impossible.
FIG. 9. Four eggs of the New World
hookworm, Uncinaria americana, in
the 1, 2, and 4 cell stages. The egg
showing 3 cells is a lateral view of a
4-cell stage. These eggs are found in
the feces of patients and give a positive
diagnosis of infection. Greatly en-
larged. (After Stiles, 1902b, p. 192, fig.
127.)
21
[AGCHYLOSTOMA Dubini, 1843.]
DIAGNOSIS. Undnaria: Provided with ventral recurved teeth.
TYPE SPECIES. Agchylostoma duodenale Dubini, 1843.
The Old World hookworm AGCHYLOSTOMA DUODENALE & Dubini, 1843, or UNCINAKIA
DUODENALIS (Dubini) Eailliet, 1885 of man.
(Figures 10 to 41.)
SPECIFIC DIAGNOSIS. Agchylostoma: Body cylindrical, somewhat attenuated ante-
riorly. Buccal cavity with two pairs of ventral teeth curved like hooks, and one
pair of dorsal teeth directed forward; dorsal rib not projecting into the cavity.
Male, 8 to 11 mm. long; caudal bursa with dorso-median lobe, and prominent lateral
lobes united by a ventral lobe; for rays, see fig. 14; dorsal ray divides at a point
two-thirds its length from ita base, each branch being tridigitate; spicules long and
slender. Female, 10 to 18 mm. long; vulva at or near posterior third of body. Eggs,
ellipsoid, 52 to 60 ju by 32 JLI, laid in segmentation. Development direct without inter-
mediate host.
' ? There are numerous ways of spelling this word (see p. 15), more than one with
moiv or less philological authority. Under these circumstances I adopt the original
orthography, despite the fact that it is not philologically correct. By this action I
do not intend to necessarily reject the ruling covered by the International Code, but
from practical experience I find it impracticable to carry out said rule in reference
to the emendation of names until the question of homonyms is decided.
^SYNONYMY, WITH ORIGINAL PLACE OF PUBLICATION.
1843: Agchylostoma duodenale DUBINI <Ann. univer. di med., Milano, T. 106, aprile,
pp. 5-13, pi. 1, figs. 1-5; pi. 2, figs. 1-3.
1845: Ancylostoma duodenale (Dubini) CREPLIN <Arch. f. Naturg., BerL, 11. J., v. 1,
p. 325.
(1846): Anchylostoma duodenal^ (Dubini) DELLE CHIAJE <Rendicon. dell' Accad.
delle sci., Napoli, v. 5, p. 339. [Not verified.]
1850: Anchylostoma duodenale (Dubini) DUBINI, Entozoografia umana, pp. 103-112.
1851 : Anchylostomum duodenale (Dubini) DIESING, Systema helminthum, v. 2, p. 322.
?(1851) : Strongylus quadridentatas SIEBOLD <Naturforsch. Versamml. z. Gotha. [Not
verified.]
1861: Dochmius anchylostomum MOLIN, II sottordine degli acrofalli <Mem. r. 1st.
ven. di sc., lett. ed arti, Venezia, v. 9, pp. 485-487.
1864: Sclerostoma duodenale (Dubini) COBBOLD, Entozoa, pp. 361-362, fig. 77.
1866: Strongylus duodenalis (Dubini) SCHNEIDER, Monographic der Nematoden, BerL,
pp. 139-140, 1 fig., pi. 9, fig. 3.
1866: "Ancylostomum duodenate Dubini" of WHITE <Boston M. & S. J., v. 75 (21),
Dec. 20, p. 427. [Misprint for duodenale,]
1876: Dochmius duodenalis (Dubini) LEUCKART, Die menschlichen Parasiten, v. 2 (3),
pp. 410-460, figs. 235-239, 241-247, 249.
1879: Anchilostoma duodenale (Dubini) BOZZOLO <0sservatore, Torino, v.. 15 (24),
17 giugno, pp. 369-370.
1881: Docmius duodenalis <Rev. med. de la Suisse Rom., Geneve, v. 1 (3), 15 mars,
p. 190.
1885: Undnaria duodenalis (Dubini) RAILLIET, Elements de zool. med. etagric., Par.,
pp. 357-359, figs. 245-248.
1897: Anchylostamum duodenale (Dubini) MCEHLAU < Buffalo M. J., v. 36 (8), Mar.,
pp. 573-579. [Misprint for Anchylostomum duodenale.]
Ankylostoma tlnodetia/e and Ankylostomum duodenale of various authors.
22
cut
FIG. 10. Dorsal view of anterior end of the Old
World hookworm (Agchylostoma duodenale) of
man. Greatly enlarged. (After Perroncito,
1882, p. 339, fig. 140.)
FIGS. 11-12. Old World
male and female
hookworms (Agchy-
lostoma duodenale) of
man. Natural size.
(After Stiles, 1902b,
p. 187, tigs, lift, llfi.1
FIG. 14. Semidiagramrnatic figure of the caudal
bursa of an Old World male hookworm (Agchylo-
stoma duodenale) of man. (After Railliet, 1886, p.
357, fig. 247.)
FIG. 13. Old World fe-
male hookworm (.!(/-
Chyloxtonia ihnxli IHI/I )
of man, greatly en-
larged diagram to
show the anatomy:
a., anus; b. c., buc-
cal capsule; cnl., cul
de sac of ovary; c.,
esophagus; int., intes-
tine; u. a. anterior ut-
erus; 11. p., posterior
uterus; v., vulva and
vagina. (AfterSchul-
thess [copied from
Blanchard, 1888a, p.
761, tig. 374].)
HABITAT. In small intestine of man (Homo sapiens)', also alleged to occur in
certain apes. Africa, Europe, Asia, Philippines, introduced into America.
FIG. 15. Male hookworm (Agchylostoma duodenale) of man; ac. p.,
accessory piece to spicules; a. p., "anal papilla;" 6. c., buccal cap-
sule; can. cerv. gl. s., canal of left cervical gland; cerv. gl. d., right
cervical gland; cerv. gl. s., left cervical gland: cu., cuticle, cul., cul
de sac of testicular tube; e., esophagus; e', posterior end of esopha-
gus; e. p., yentromedian excretory pore; ej. can., ejaculatory canal;
int., intestine; 1. r., lateral ray of bursa; m., muscular layer; p., lat-
eral prsecaudal papilla; sp., spicules; sp r , anterior end of spacules;
test., testicular tube; ves. sem., vesicula seminalis; v. r., ventral rays
of bursa. Greatly enlarged. ( After Schulthess [copied from Blanch-
ard, 1888a, p. 755, fig. 370].)
24
LIFE HISTORY OF AGCHYLOSTOMA DUODENALE OR UNCINARIA
DUODENALIS.
The eggs (tig. 16) are laid in the intestinal tract of the patient by
the female worms and are discharged in the feces, either unsegmented
or during the early stages of seg-
mentation. They will not develop
into adult worms in the intestine,
but must first pass out of the body.
Thus, for every adult hookworm
present in the bowels a separate
germ must enter the body.
The egg has a thin shell, which is
an indication of a simple life cycle.
A short time after escaping in the
feces the time varying according
to temperature, moisture, and posi-
tion in the feces each egg devel-
ops (figs. 17-27) a minute embryo,
which is known as a rhabditiforrn
embryo (fig. 27). This name is given
to it because of its resemblance to
worms of the genus Rhabditis. Characteristic for this stage is the
rhabditif orm esophagus, which is entirely different from the esophagus
FIG. .16. Eggs of Old World hookworms
(Agchylostoma duodenale) as found in the
stools. Greatly enlarged. (After Stiles,
1902b, p. 193, fig. 128.)
FIGS 17-29. Embryology of the Old World hookworm (Agchylostoma duodenale) of man; 17-23, seg-
mentation of the egg, 24-26, the embryo; 27, a rhabditiform embryo escaping from its eggshell; 28-29,
empty eggshells. Greatly enlarged. (After Perroncito, 1882, p. 342, fig. 142.)
of the adult hookworm. This embryonal esophagus is more or less
bottle shaped, and consists of three parts an anterior elongated
25
swollen portion, followed by a thin middle portion, the latter being
followed by a more or less globular esophageal bulb which possesses a
triradiate chitinous armature. This kind of esophagus is common to
the early stage of all members of the family Strongylida? and also to
numerous other free-living or parasitic nematodes. It is evidently a
worm with an esophagus of this sort
which was recently found in the earth
taken from the New York tunnel ex-
cavations, and upon which was based
the report that uncinariasis was
' .present.
The embryo of the hookworm lives
in water or moist ground. In its
evolution the worm casts its skin
four times, thus passing through
five stages, and changes its structure
so as to assume more and more the
characters of the adult. During
these changes the sexes become dif-
ferentiated. Some of these changes
occur in water or moist ground, and
the rest after infection takes place.
DEVELOPMENT OUTSIDE THE BODY.
The eggs develop
best in the unaltered fecal matter,
especially when this is well formed;
not so well when it is more fluid in
character. The addition of water
retards the development, and if con-
siderable water is added the eggs
perish. Air is necessary to develop-
ment, and the eggs nearer the sur--
face of the feces segment more rap-
idly than those in the center. At a
temperature of about 27 C. the em-
bryo may form and escape from the
shell in twenty-four hours. Lower
temperatures retard development, so
that at 21 or 22 C. the embryo may not escape for from thirty-six
to forty hours; 1 C. kills the eggs in twenty-four to forty-eight
hours, so that freezing weather may be looked upon as disinfecting
areas exposed to the cold.
Embryo. Upon escaping from the shell, the embryo (tig. 27) meas-
FIGS. 30-31. Two larvae of the Old World
hookworm at the end of the second stage
("encysted larvae"), representing the
young worms retracted from their skin.
(After Perroncito, 1882, p. 350, figs. 148 a-b.)
ures 0.3 mm. in length; the anterior end is blunt, the tail long and
pointed; 6 points are visible around the mouth, and these develop
later into the papillae; jthe buccal cavity is 10 jw long, 1.4 /^ in diameter,
and possesses a highly refractive chitinous membrane; the anus is 50 /*
from the tip of the tail; excretory pore 50 /* from anterior end; 160
ju from anterior end is seen the primordium of the genital system.
In this stage the embryo takes food and grows. About the second
...ft. m.
32
FIG. 32. A young hookworm (Agchylostoma duodenale) of man, without buccal capsule, four days
after infection: a, anus; c. g., cervical gland; g, primordium of genital organs; n. s., nervous sys-
tem; p., papillae on head; p. e., excretory pore; p. m. c., primary mouth cavity. X about 190 times.
(After Looss, 1897, p. 919. fig. 1.)
FIG. 33. Anterior end of a young hookworm (Agchylostoma duodenale) during formation of pro-
visional buccal capsule: c. g., cervical gland; e. g. d., dorsal esophageal gland; e. g. v., ventral
esophageal gland; n. m., new mouth; p., papillee on head; p. e., excretory pore; p. m. c., primary
mouth cavity. X 578. (After Looss, 1897, p. 920, fig 2.)
FIG. 34. Head of larval hookworm (Agchylostoma duodenale) before entering fourth stage, five or six
days after infection; n. m'., new mouth; p. c. m., primary mouth cavity, which extends through
the provisional buccal capsule and continues as lumen of the esophagus. X 578. (After Looss, 1897,
p. 921, fig. 3.)
or third day the embryo casts its first skin, but does not change its
organization. After about four or five days (at 27 C.) it measures
480 fit long by 30 /* in diameter.
Second stage. After the fifth day the young worms begin to show
signs of a second ecd}^sis, at the same time undergoing certain other
changes. Three minute lips, each with two very delicate papillae,
appear under the skin at the anterior end; the brightly refringent cutic-
27
ular lining of the buccal cavity and the chitinous teeth of the esopha-
geal bull) disappear; the esophagus elongates, becomes thinner, and its
three divisions become less distinct; the tail becomes slightly shorter
and more blunt; the anus lies 90 ^ from the tip of the tail. The organ-
FIG. 35. Young hookworm (Agchylostoma duodenale) in fourth stage, with provisional buccal capsule:
c. <j., cervical gland; g., primordium of genital organs; n. $., nervous system; p. e., excretory pore.
X 105. (After Looss, 1897, p. 921, fig. 4.)
FIG. 36. Provisional buccal capsule (fourth stage) of a larval hookworm (Agchylostoma duodenale),
about nine days after infection: p. b. c., primordium of definite buccal capsule. X about 420. (After
Looss, 1897, p. 921, fig. 5.)
FIG. 37. Young male hookworm (Agchylostoma duodenale), nine days after infection : a., anus; c. g.,
cervical gland; g., genital tract; p. b., primordium of bursa ; p. e., excretory canal ; p. sp., primor-
dium of spicules. X about 105. (After Looss, 1897, p. 922, fig. 6.)
ism becomes more motile, and contracts from its outer skin, thus form-
ing the stage (figs. 30-31) which has been described as an " encystation,"
but which in reality is simply a second ecdysis. This is the infecting
stage of the hookworm, and ends the development so far as the free
life is concerned. No more food is taken. In some cases, however,
28
the worm escapes from the surrounding cast skin. While water is
more or less injurious to the egg and the first stage, the infecting
" encysted" stage exists well in this medium, and Looss (1897) suc-
ceeded in keeping these worms alive for thirty days in water. Upon
drying up the larvre die, so that the view that the worms exist in dust
and are carried around in the air, thus leading to infection, is not well
founded (see p. 30).
DEVELOPMENT INSIDE THE BODY.
Upon being swallowed these young worms undergo further ecdyses,
changing their internal organization at the same time. We, may
recognize, with Looss, a third stage, without buccal capsule (fig. 32);
a fourth stage, with a provisional buccal capsule (fig. 35); finally, a
fifth stage, with the definite buccal capsule, corresponding to the adult
form.
Third stage (without buccal capsule, fig. 32). During their free life
the larvae may attain 0.65 to 0.7 mm. in length by 25 to 27 V in diam-
38
FIGS. 38-39. Development of definite buccal capsule (38, 011 twelfth day after infection; 39,. one
or two days later): d. b. r., definite buccal capsule; e. g. d., dorsal esophageal gland; m. m., margin
of definite mouth ; p, papillae on head ; p. b. c. d., p. b. c. v., dorsal and ventral primordia of the
definite buccal capsule ; p. t., primordium of ventral tooth ; t., ventral tooth ; the new cuticle can
be distinguished under the old. X 190. (After Looss, 1897, p..923, figs. 7-8.)
eter (at the end of the esophagus). The esophagus is 160 ^ long, and
its three divisions may still be distinguished. The intestine is com-
posed of about 15 rows of two cells each.
Fifteen hours after infection of dogs the worms have passed below
the stomach. They now begin to feed, but their growth is compara-
tively slow. After about five days they begin to show signs of a
third ecdysis, which continues until about the seventh day. During
this period important changes take place, especially at the anterior
end, arid result in the formation of the provisional buccal capsule.
Fourth stage (with provisional buccal capsule, fig. 35). This is
the fourth larval stage, namely, the stage after the third ecdysis. The
worms have not increased notably in length, but certain organs are
advanced in development, and the esophagus no longer shows its for-
mer three divisions. The worms measure about 0.66 mm. long by 25 /*
in diameter, the latter being nearly uniform for a greater part of the
29
length (fig. 8;5). The provisional buccal capsule attains 40 /* in diam-
eter, and the mouth is bent slightly dorsad. Two pairs of teeth are
visible at the base of the capsule one pair situated dorsal ly, the other
ventraljy. During this stage the animal increases in length and thick-
-Me...
FIGS. 40-41. Male and female hookworms (Agchylosloma duodenale) during the fourth easting of skin
14 to 15 days after infection: a., anus; c. g., cervical gland; c. o. e., cuticle of old esophagus; c. *
cast skin; d. b. c., definite buccal capsule; g., genital organs; I. g., large ganglion, supplying the
rays of the bursa; m. a., anal muscle; n. c. gl., nucleus of cervical gland; p. e., excretory pore:
p. b. c., provisional buccal capsule; r. in. sp., retractor muscles of spicules; sp., spicules; v., vulva.
X 42. (After Looss, 1897, p. 924, figs. 9-10.)
ness, the inner organs become better developed, the sexes become
differentiated, and the definite buccal capsule forms at the anterior
end. With these changes the parasite prepares for its last namely,
a fourth ecdysis, which occurs about fourteen to fifteen days afte-
infection.
30
Fifth stage (with definite luccal capsule). The worm is now about
1.9 (male) to 2 mm. (female) long, 12 to 14 /* in diameter very much
smaller than the adult forms. It is estimated that the parasites
require about four to five or six weeks from the time of infection to
become mature.
SOURCE OF INFECTION OF UNCINARIASIS.
The worms may be swallowed in contaminated food or in drinking
water during or after the second ecdysis. Persons handling dirt are
especially apt to get the microscopic worms on their Hands, and it is
an easy matter to transfer them to the mouth, either directly by biting
the finger nails or sucking the fingers, or indirectly with food. In
prevention, therefore, careful personal habits and pure drinking water
are indicated.
Some writers state that the young stages are scattered in the air by
the wind and in a dry state, the inference being that they may then
be breathed in or may contaminate food. While not caring to go to
the extreme of stating that such a method of dissemination or infection
is impossible, my own observations on this class of parasites do not
lead me to attach any importance to aerial infection. As a rule,
drying-out results in a high mortality among nematode larvae, embryos,
and eggs, while moisture, on the other hand, is necessary for their
existence. Now, uncinariasis is not so common as to fill the air with
dried larvae, and the chances of inhaling the latter appear to be almost
infinitesimally small. Since the worms do not increase in number in
the intestinal tract-, we should therefore expect (in case aerial infection
were common) to find rather few cases of severe infection, but a more
or less uniform light infection of nearly all persons or animals inhabit-
ing an infected area, since all are breathing the same air. Further, as
adults breathe more air than children we should expect the former to
present the cases of heaviest infection. We should also expect to find
the disease more general in dry years than in wet seasons. Such, how-
ever, does not appear to be the case. Cases of infection vary greatlv
in intensit} T , and the losses from nematode diseases in sheep are much
less in dry years and in dry localities than in wet seasons. As a
matter of fact, few factors can be conceived of which would probably
result in killing more germs of the disease than would dry winds.
In preventing uncinariasis and nematode diseases in general among
live stock, systematic draining and burning of pastures are strongly
advocated.
Looss (1898, 1901) recently suggested that the larvae may enter the
human body by way of the skin and then pass through the body to
the intestine. Startling as this view is, Looss (see Sandwith, 1902)
has recently demonstrated the correctness of it. (See p. 59.)
31
BRIEF REVIEW OF UNCINARIASIS.
Uncinariasis is by no means a new disease. According to Sandwith
(1894), a medical papyrus, written about three thousand four hundred
and fifty j^ears ago, embraced in an encyclopedic form the knowledge
at that time of Egyptian teachers. This oldest of all books among
medical works (Eber's papyrus) came into the hands of Professor
Ebers at Thebes, in 1873, and has recently been translated into German.
Dr. Joachim (1890) and Scheuthauer (1881) agree that anemia, due to
hookworms (Agchylostoma duodenale), was well known to physicians
of those days under the name of " AAA" and " UHA." The papyrus
describes accurately among the symptoms, "heart weakness, palpita-
tion, stabbing cardiac; pains, constipation, edema of the legs, a weight
ih the body pressing heavily, and other digestive troubles." It further
prescribes a remedy for a patient who has in his body worms, which
are produced by the " AAA" disease, and possibly it is the hookworms
which are referred to.
Within modern times this special form of anemia was described in
Brazil by Piso in 1648; Labat (1742 or 1748) observed it in Guadeloupe,
Chevalier (1752) in St. Domingo, Dazille and Bason (1776) in the
Antilles, and Edwards (1790 or 1793) in Jamaica. In Europe, the
disease was first noted among the miners of Anzin in 1802.
Not until 1843 was the parasite (Agchylostoma duodenale) described,
when Dubini of Milan published an account of it. Later it was reported
from Egypt, Germany, -France, India, Ceylon, Japan, Australia, and
elsewhere, and to it was attributed a certain widespread anemia of
brickmakers, tunnelers (St. Gothard tunnel anemia), and miners.
Zinn and Jacoby (1898), who have compiled 464 bibliographic refer-
ences to the disease, give two charts showing its distribution at the
time their paper was published.
In studying the maps, it will be well to recall that at the time they
were printed nothing was known regarding the relations of uncinari-
asis to the soil (see p. 47), hence, the areas which are given as infected
are probably much greater than the actual extent of the infested terri-
tory; further, the maps would indicate that they have registered the
places in which hookworm disease has been diagnosed, and not neces-
sarily the areas in which hookworm infection occurs.
In connection with their references to the United States, they simply
mention Georgia, Alabama, and Louisiana, saying that there is little
to report upon this subject for these localities.
32
BRIEF REVIEW OF UNCINARIASIS IN THE UNITED STATES.
In order to understand the American publications on this disease, it
must be stated that much of the so-called "dirt-eating," "pica,"
"cachexia africana," antebellum "negro consumption," "mal d'esto-
mac," "malnutrition," and "malarial anemia," described for the
Southern Atlantic States, is in reality due to uncinariasis.
The earliest reference which seems quite positively to refer to this
disease in this country, so far as I have yet found, is an article by
Dr. Pitt (1808, pp. 340-341), who says that along the Roanoke River,
North Carolina, malacia or dirt-eating "prevails mostly among the
poor white people and negroes, and originates, in my opinion, from
a deficiency of nourishment." Chabert's (1821) description of the con-
ditions of the slaves of Louisiana, which he attributed to dirt-eating,
Jordan's (1832, of Person County, N. C.) account of "cachexia
africana, or negro consumption," Cotting's (1836) account of the dirt-
eating in Richmond County, Ga., Little's (1845) description of the
dirt-eaters of Florida, Le Conte's (1845) account of the dirt-eating in
the pine barrens of Georgia, Duncan's (1850) record of dirt-eaters in
St. Mary's Parish, -La., all apply so well to the uncinariasis I studied
in some of the same States that I have no hesitation in assuming that
many, if not all, of the cases were due to infection with Uncinaria.
Lethermann (Florida), Lyell (Georgia and Alabama), and Heusinger
and Geddings (South Carolina) are said to have published on similar
conditions in the South, but not being able to trace their articles, I
am unfortunately unable to give them full credit for whatever views
they may have advanced.
Blickhahn (1893a) seems to have been the first physician to recognize
as such and to publish a case of uncinariasis for this country. The
patient was a German brickmaker who had been in the United States
seventeen months, and Blickhahn believes the infection took place in
Germany. It is true that Herff (1894) records a case of supposed
uncinariasis observed in Texas in 1864, and Allen J. Smith (published
by Schaefer, 1901) found Uncinaria eggs in feces of man in Texas in
1893, but these publications are antedated a by Blickhahn's article;
hence Blickhahn has priority of discovery. It is, however, interesting
to note that Blickhahn's case, being in a German, was probably caused by
the Old World parasite, Agcliylostoma duodenale, while the cases of
Herff and Allen J. Smith were in all probability the first endemic cases
recognized. Herff did not appear altogether certain regarding his
diagnosis, but his short account of the worm indicates that the inter-
pretation is correct.
In all zoologic matters neither priority of observation nor priority of presentation
before a scientific society avails to give priority of discovery. By international
agreement, and by custom extending back a century and a half, zoologists recognize
only actual publication as governing a question of this sort.
33
Moehlau (1896) reported five cases for Buffalo, N. Y., which were
supposed to be due to the Old World parasite (Agchylostoma duodenale).
Gray (1901) recorded two cases for Richmond, Va., contracted else-
where in the same State, which he states positively (personal conver-
sation) were due to Agchylostoma duodenale, and Tebault (1899)
recorded a case of uncinariasis in a boy of German descent in New
Orleans.
To one of my former pupils, Dr. Bailey K. Ashford (1900), of the
U. S. Army, is unquestionably due the credit of having first seriously
.directed the attention of American physicians and zoologists to this
disease/' Ashford in fact found this malady very common in Porto
Rico, and although he erroneously considered the parasite to be iden-
tical with the Old World species, his clinical observations placed the
American medical profession on its guard for cases which might occur
in returning American troops.
In 1901 there was a sudden increase in American observations.
Dyer (March 15, 1901) reported a case for St. Louis. Schaefer (May,
1901) was reported in the proceedings of the Texas Medical Associa-
tion (Texas Medical News, May, 1901) as presenting a paper on a new
form of intestinal parasite in Texas. The case in question was uncina-
riasis, probably due to Uncinaria americana, but was not published as
uncinariasis until October 26, 1901.
Claytor's (June, 1901) case is, so far as I am aware, the first pub-
lished American case which can be recognized as unquestionably due
to Uncinaria americana, although at least some (and probably most, if
not all) of Ashford's cases were caused by this species. Claytor's case
was originally published as an infection with the Old World species,
Agchylostoma duodenale (an error for which the responsibility rests
upon me, not upon Dr. Clay tor; the large-sized egg found should have
placed me more on my guard).
Allyn and Behrend (July 13, 1901) recorded an imported case in an
Italian boy in Philadelphia, due apparently to Agchylostoma duodenale,
and at the same time mentioned three unpublished cases diagnosed by
Dr. L. Napoleon Boston, two in 1900 and one in 1901. All three cases
came from Porto Rico, so that they were probably due to Uncinaria
americana.
It is true, as has been stated, that for some years prior to Ashford's publication
I had repeatedly insisted upon the probability of the frequent occurrence of this
disease in the United States, having discussed the subject in my lectures on medical
zoology in the post-graduate medical school of the U. S. Army, and in the medical
classes of Johns Hopkins University and of Georgetown University (the latter, the
alma mater of Dr. Ashford), as well as in various medical meetings; but so far as I
am aware, my views were not printed until July, 1901, so that Ashford's printed
statements antedate mine by more than a year. Furthermore, his paper was a
practical demonstration, while my views were theoretical deductions.
19558 No. 1003 3
34
In a paper (July, 1901) written for the Texas Medical News 1
expressed very positive views to the effect that uncinariasis in man
must be more or less widespread in the United States, and I discussed
the disease in general. The position taken was based upon general
zoologic principles, and, so far as 1 am aware, was the first printed
definite claim regarding the frequency or probable frequency of the
malady in the United States.
Schaefer (October 26, 1901) next published a ,case for Galveston,
Tex., probably infected in Mexico, and made the very important
statement that Allen J. Smith had found pne case in Galveston in
1893, and since then that he had encountered two [afterwards six addi-
tional] cases among some 80-odd medical students of the University
of Texas.
The importance of this discovery by Allen J. Smith should not be
underestimated. To the clinician it did not mean very much, since
no record existed that the students exhibited any very severe symp-
toms. To the zoologist, however, it meant a practical demonstration
that uncinariasis was more or less common in the South. Here were
3 [9] students in a city (Galveston); the chances that the infection took
place in Galveston did not seem very great; as the students came from
different places (according to personal information), the infection must
be more or less widespread; and since light cases occurred among
medical students, heavier infections must naturally occur among per-
sons who come more regularly in contact with the dirt. Allen J.
Smith's observations, the importance of which has not yet been duly
recognized by medical journals or by his colleagues, led to some cor-
respondence between himself and me, and he very kindly forwarded
specimens from one of his cases. In some respects these parasites
resembled Uncinaria stenocephala of the dog, and both Allen J. Smith
and I were fully agreed that they were not identical with Agchylo-
stoma duodenale. I obtained specimens from Claytor's case and also
some material which Ashford had sent from Porto Rico to the U. S.
Army Medical Museum. All three lots of worms agreed with each
other, and differed from Uncinaria stenocephala, which I had obtained
from Europe, as well as from U. trigonocephala a from sheep, U.
radiata from cattle, U. Lucasi from the Alaskan seal, and from every
other species of Uncinaria of which 1 could obtain either specimens
or description. Accordingly, I described (May 10, 1902) these worms
as a new species, naming it Uncinaria americana.
Having now an endemic species, with specimens in my possession
for Washington, D. C. (patient came from Virginia), Porto Rico
(Ashford's material), Cuba (specimens sent by Guiteras), and Galves-
ton (Allen J. Smith's material), I did not hesitate to state positively in
U. cernua (Creplin, 1829). See Stiles, 1902b, p. 189.
35
a paper published in the Eighteenth Annual Report of the Bureau of
Animal Industry, and issued on September 25, 1902, that we must have
in the United States an endemic uncinariasis which had been generally
overlooked.
Prior to the appearance of the paper in question, Claude Smith, of
Atlanta, Ga. (June, 1902), had presented a case of uncinariasis before
the American Medical Association (see below, p. 103), the parasite
afterwards proving to belong to the species Undnaria americana.
H. F. Harris (July 19 , 1902), also published a case of uncinariasis
(see below, p. 103) for Georgia. In reply to a letter from me, he stated
(August 9) that he had found other cases also, and that he was " abso-
lutely sure this disease is very common in this [Porter Springs]
locality."
Upon my transfer from the United States Bureau of Animal
Industry to the United States Public Health and Marine-Hospital
Service, I decided upon an early study of uncinariasis in man, to
determine its frequency and geographic distribution in the Southern
States. A preliminary report (Stiles, 1902c, October 24) was pub-
lished, giving my results for Virginia, North Carolina, and part of
South Carolina. This report reads as follows:
[Reports to the Surgeon-General Public Health and Marine- Hospital Service.]
HOOKWORM DISEASE IN THE SOUTH FREQUENCY OP INFECTION BY THE PARASITE
(UNCINARIA AMERICANA) IN RURAL DISTRICTS.
(Preliminary report by Dr. Ch. Wardell Stiles, chief of Division of Zoology, United
States Public Health and Marine-Hospital Service, detailed for this investigation. )
KERSHAW, S. C., October 22, 1902.
SIR: Through the director of the Hygienic Laboratory, I have the honor to submit
a brief preliminary report in regard to the frequency and geographic distribution of
hookworm disease (uncinariasis) in the Southern States.
Meeting the disease in the Virgilina copper-mine district of southern Virginia and
northern North Carolina, I have thus far traced it through the coal-mine district of
Cumnock, N. C., the brickyards of Camden, S. C., and the granite-sand district of
Lancaster and Kershaw counties, S. C.
The present indications are that it is more prevalent in sandy regions than in clay
or stone districts. On the farms and plantations of the sand region of the two
counties just mentioned, it appears to be the most common disease of man, and from
an economic point of view it appears to be of great importance. The extreme cases
seem to occur more commonly among children and women than among adult males
over 25, but the present facts at my disposal do not indicate that the malady is quite
so fatal as the European form of the disease caused by Undnaria duodenalis. All of
the cases thus far examined are due to Undnaria americana, demonstrating clearly
that this is an endemic infection and totally independent of the cases which have
been introduced from Europe, Asia, and northern Africa.
In general, it may be said that the "pale skin," the "heart disease," the
"diarrhea," the "bloat," and the suppression of menses which I have thus far
examined all represented various stages of heavy infections with Undnaria americana,
and it is impossible to escape the conclusion that so far as the farms and plantations
36
are concerned a radical change in the general therapeutics practiced in the localities
in question is urgently indicated.
As for the economic side of the problem, it should he recalled that the disease in
question is resulting in loss of wages, loss in productiveness of the farms, loss in
the school attendance of the children, extra expenses for drugs and for physicians'
services, etc.
The heavy and frequent infections found are amply explained by the almost total
absence of privies and closets on the farms visited. Defecation occurs at almost any
place within a radius of 50 meters from the house or hut, and as a result the prem-
ises become heavily infested with the embryos.
The disease as thus far traced is primarily a "poor man's" malady, and in fre-
quency it far exceeds even the most extreme limit which theoretical deductions
seemed to justify before commencing the field work. There is, in fact, not the
slightest room for doubt that uncinariasis is one of the most important and most
common diseases of this part of the South, especially on farms and plantations in
sandy districts, and indications are not entirely lacking that much of the trouble
popularly attributed to " dirt-eating," "resin-chewing," and even some of the pro-
verbial laziness of the poorer classes of the white population are in reality various
manifestations of uncinariasis.
The infection among the miners, so far as discovered, is less severe and less com-
mon than the infection on the farms and plantations of the sandy districts.
Respectfully,
CH. WARDELL STILES, Ph. D.,
Chief of Division of Zoology.
On November 15, Dr. H. F. Harris, of Atlanta, Ga., published an
important notice regarding uncinariasis in the South. After refer-
ring to his first case (see above, p. 35), he says:
" The discovery of a distinct American species of the hookworm is very important,
as it leads to the inference that the aborigines of this country were infested with this
parasite, and that the worm is probably present in all parts of the United States
where the conditions are suitable for its development.
"My observations during the last six months bear out this assumption in a most
striking manner. A few weeks after my first case of the disease was seen, a second
one was encountered that originated in middle Georgia, but though I was constantly
on the search for it no other case was found among the numerous patients that come
to the clinics of the Atlanta College of Physicians. In June of the present year I
made a trip to north Georgia, a region that has long been noted as one in which the
inhabitants are very pale and anseinic, this condition being commonly reputed to be
the result of dirt eating. Here I saw many instances of what was in all probability
ankylostomiasis; but as a result of the ignorance of the people and their suspicion of
all strangers a proper examination could be obtained in only four cases, in all of
which the parasite was demonstrated. Subsequently a case of the disease was seen
that originated in middle Alabama. During September and October I have been
studying malaria in south Georgia and Florida, a region in which the people show
profound ansemia even more often than in north Georgia. This condition is com-
monly ascribed to malaria, but my observations show that in almost all instances the
sufferers have no malarial parasites in their blood, but eggs of the ankylostoma are
constantly found in the feces. During my entire stay in this region I only saw one
case of profound ansemia from malaria, and in this instance the patient did not exhibit
the extraordinary ansemia so commonly found in those infected with the ankylostoma.
I feel no hesitation in saying that time will show that by far the greater number of
cases of ansemia in Georgia, Alabama, and Florida are due not to malaria but to
the ankylostoma, and that this is the most common of all the serious diseases in this
37
region. There can be no reasonable doubt that what is true as regards the States
named likewise holds good for the entire South. Since rny first case was reported
13 other instances of the disease have been seen 1 1 originating in this State, and
1 each in Florida and Alabama; and if all of those encountered who were suffering
from anaemia could have been examined there can be no doubt that the number
would be many fold greater.
"This communication is written in the hope that Southern physicians will take up
this most important matter at once, for in no other serious disease does the victim
suffer so long, in no other condition is he for such a period a menace to those about
him, and in no other malady of such gravity is the treatment so rapidly and surely
successful."
ITINERARY OF TRIP THROUGH THE SOUTHERN ATLANTIC STATES.
DISTRICT OF COLUMBIA.
In September, 1902, with the aid of three assistants (Messrs. P. E.
Garrison, B. H. Ransom, and E. C. Stevenson) I began a systematic
study of animal parasites among the patients of Government Hospital
for the Insane, District of Columbia. From September 10 to Decem-
ber 12, 1902, the stools of 500 male a patients were examined micro-
scopically and 15 patients, or 3 per cent, were found to be infected
with hookworms. The history has not yet been examined for each
case, but probably most of the patients became infected in Cuba,
Porto Rico, or the Philippines.
VIRGINIA.
Richmond and State farm. Starting on my field work, my first
stop (September 25) was Richmond, Va. Through the courtesy and
cooperation of DA Charles V. Carrington I was able to examine at
the State penitentiary^ and the State farm nearly 1,200 convicts. The
prisoners filed past Dr. Carrington and myself in single file, and we
selected those who appeared anemic or debilitated. Those selected
were sent to the hospital and kept there until specimens of feces were
obtained. In microscopic examination of 6 white male convicts no
case of uncinariasis was found. The only zooparasitic case noticed
was an exceedingly heavy infection with whip worms (Trichuris
trichiura) in a man about 70 years old.
In 22 male negroes the examination was likewise negative so far as
Uncinaria was concerned, but one case of infection of eelworms
(Ascaris lumbricoides) was found. In several of the convicts starch
digestion or meat digestion was poor, but in most instances the debili-
tated condition was due to tuberculosis or other diseases.
At the almshouse in Richmond 1 white female 28 years of age gave
negative results; a weak-minded girl of 7 years showed a heavy
infection with whip worms (Trichuris trichiura). In two negroes (1
male, 28 years; 1 female, 30 years) the examination was negative.
In 350 female patients examined to March 1, 1903, only one case of hookworm
infection has been found.
38
It proved to be so difficult to obtain specimens of feces from the
brickyards that no microscopic examinations were made. No clew
was obtained to any disease among the workers which could be inter-
preted as probable uncinariasis.
Besides Dr. Carrington, I am indebted to Dr. Staton also for
cooperation in my work at Richmond.
NORTH CAROLINA.
Virgilina Copper Mine district, southern Virginia and northern
North Carolina. Proceeding to the Virgilina copper mine district I
found it very difficult at first to obtain specimens for examination.
At one mine 1 white male and 3 negro males were examined; all were
negative except 1 negro 22 years old, who showed infection with
Ascaris lumbricoides. At this mine defecation under ground is pro-
hibited; it occurs in the surrounding woods, at any place within a
radius of about 50 meters from the shaft.
At a second mine three specimens of feces were taken at random
from the woods; eggs of Uncinaria americana were found in one
specimen, and ova of Ascaris lumbricoides in a second. The patients
could not be traced. Specimens were then obtained from 4 white and
18 negro miners, the feces being taken without reference to the
physical condition of the men. Of these 22 men, 1 negro 25 years
old showed a light infection with Uncinaria americana, and inquiry
developed the fact that he u had not been well for some time." His
chief complaint had been "diarrhea." In two other cases, a white
man 41 years old and a negro 34 years old, eggs of the eelworm (Asca-
ris lumbricoides} were found. At this mine defecation under ground
is prohibited, and a box privy is located within about 50 meters of
the shaft. The men prefer, however, to defecate in the surrounding
woods.
1 am indebted to Drs. F. D. Drewry and P. P. Causey, and to Mr.
L. N. White, manager of the Person Consolidated Copper and Gold
Mines Compan}^ at Durgy, N. C., for their kind cooperation in con-
nection with my work in Virgilina and vicinity.
Cumnock Coal Mines, Chatham County. The miners at this place
were so suspicious regarding my work that it was almost impossible
to obtain specimens for examination. In fact only two specimens
could be obtained from about 40 men. One of these, a white miner,
52 years of age, and in rather anemic condition, showed infection with
Uncinaria americana. The other, a white engineer, 34 years old,
gave negative results.
Sanford, Moore County. Specimens from 4 whites (2 males, and 2
females), obtained by 2 of the local physicians, were examined with
negative results.
39
SOUTH CAROLINA.
Camden, Camden County. Unexpectedly delayed at Camden, I
visited the brickyards with Dr. J. W. Corbett. Of 7 specimens of
feces picked up at random from the ground, probably most if not all
from negroes, 1 was found infected with Uncinaria americana. One
white laborer also showed infection with the same parasite.
Haile Goldmine, Lancaster County. Through the kindness of Cap-
tain Thiess, the superintendent of the mines, and Dr. Gregory, the
local physician, I was able to examine specimens from 5 white men
and 5 negroes connected with the mine. All of these examinations
were negative.
Upon leaving Richmond I happened to recall the observation made
by Lucas (in Jordan & Clark, 1898, p. TO) in connection with uncina-
riasis of the seal pups of Alaska, namely, that the infected animals
were almost invariably found on the sand rookeries; I also recalled
that I had observed severe outbreaks of uncinariasis in sheep and
goats on more or less sandy pastures, and further that a severe out-
break of the same disease among dogs had once been reported to
me as occurring in a sandy yard. Not recalling at the time any
similar observation for uncinariasis in man, I determined to test the
subject at the first opportunity, and from Richmond to Haile Gold-
mine I had diligently inquired of every physician 1 met, whether he
found more anemia on sand, clay, or rock soil. Most physicians
replied that they had paid no attention to the subject; one physician
stated that he thought anemia was more common in sandy than in
clay localities.
Through Captain Thiess I learned that the land near the mines was
chiefly a granite sand. With Dr. Gregory, I drove about 4 miles
into the sandy district in Lancaster County and found a family of 11
members, one of whom was an alleged ' ; dirt-eater. " The instant I
saw these 11 persons I recalled Little's (1845) description of the dirt-
eaters of Florida. (See Stiles, 1902b, p. 208.) A physical examina-
tion made it probable that we had before us 11 cases of uncinariasis,
and a specimen of feces from one of the children gave the positive
diagnosis of infection with Uncinaria americana. There were hun-
dreds of eggs present.
Inquiring for the largest plantation of this sand district, I was
directed to a place in Kershaw County, about 6 miles from Kershaw,
and through the kindness of Dr. Twitty and the owner of the planta-
tion, I was able to make the desired examinations. ,
There are about 60 white "hands" on this farm. Going to a
field I found about 20 at work. These 20 persons, men, women, and
children, corresponded in more or less detail to the description of
the so-called dirt-eaters and resin-chewers. A physical examination
40
showed that they also corresponded to cases of uncinariasis. A family
of 10 members was selected and examined carefully. Specimens of
feces from 4 of them were examined microscopically and found to
contain hundreds of eggs of Uncinaria americana. The owner of the
plantation informed me that it would be a waste of my time to exam-
ine the remaining 40 "'hands," as they were in exactly the same con-
dition as the 20 already examined.
Driving to a neighboring farmhouse, 1 found a family of 5 members,
3 of whom presented such severe and typical symptoms that I had no
hesitation in diagnosing them as due to uncinariasis.
Kershaw County. While driving back to Kershaw, I passed a
country schoolhouse. The children, about twenty-five or thirty in
number, were at play during recess, and a mere glance at them was
sufficient to show that 30 to 40 per cent presented the same general
appearance as the children on the neighboring plantation.
At Kershaw several extreme cases were met on the street. The
persons in question had come in from the country. One farmer, living
about 9 miles away from Kershaw, had with him two of his children.
He stated that his entire family, 10 in number, had suffered or were
suffering in the same way as these two boys. Physical examination
made uncinariasis probable, and the microscopic examination of the
feces showed heavy infections with Uncinaria americana.
Inquiry among the local physicians and the more intelligent laity
elicited the information that the cases that 1 had seen represented
conditions which were usually attributed to "dirt-eating," "resin-
chewing," "heart disease," "bloat," "amenorrhea," "anemia due to
malaria" (mosquitoes were noticeable chiefly by their absence),
"general debility," "poor nourishment," etc. 1 was further
assured that these conditions were general throughout this region, and
were not, or only slightly, amenable to treatment.
Taking these cases together, some forty or fifty in all, which I
examined carefully within three days, we have one common symptom,
namely, anemia; nearly all other s}^mptoms noticed could be reduced
to sequelae of anemia; further, in every case examined microscopically,
exceedingly heavy infections with Uncinaria americana were found.
Under these conditions, and because the general clinical history corre-
sponded so well with uncinariasis, I have not the slightest hesitation
in grouping the cases observed as due to Uncinaria americana.
Charleston, Charleston County. Through the kindness of Drs. John
Dawson and Robert Wilson, jr., I was able to meet the students of
the Charleston Medical College. Explaining the object of my trip, I
asked for volunteers to submit to microscopic examination. Sixteen
of the students and 1 member of the faculty immediately volun-
teered. Of these IT men (all white, of course), 4 were found infected
with Uncinaria americana and 1 showed a heavy infection with
41
Hymenolepis nana. The cases of uncinariasis came from the sand dis-
tricts namely, Barn well County; Florence, Saint John County; a
sea-coast island near Charleston, and Edisto Island, Charleston County.
Through the courtesy of Dr. Huger and the ladies in charge of the
Charleston Orphan Asylum, I was able to examine 230 white children,
both boys and girls. I picked out 20 for closer examination, because
of the anemic condition, or stunted growth, etc. Of the fecal speci-
mens obtained, 15 showed infection with Uncinaria americana. All
of the children came from sandy districts of the State namely, Sum-
merville, Dorchester County; Berkeley County; Adams Run, Colleton
Count} 7 ; Plum Island, Charleston County, and McClellanville, Charles-
ton County. One additional case failed to show eggs in the feces, but
the clinical history during early childhood seemed typical for uncina-
riasis (see p. 58, case of L. B.). Of the 4 remaining cases (2 from
Charleston (city) and 2 from Edgeville), 1 Charleston boy Hi years
old and 1 Edgeville boy 11 } r ears old showed infection with whip
worms (Trichuris trichiurd).
Besides the Charleston physicians mentioned above, I am indebted
to Dr. Grange Simons, president of the State board of health; Dr. J.
Mercier Green, city health officer, and several other gentlemen, for
their kind cooperation in my work. Dr. De Saussure stated to me
that he had found the eggs of Uncinaria in the stools of several
patients.
GEORGIA.
Atlanta, Fulton County. Learning incidentally that Drs. Claude A.
Smith and H. F. Harris were continuing their studies on uncinariasis
in Atlanta, I left the city without seeing any cases personally. No
reason was apparent which made it necessary to confirm their work
for this locality, and, furthermore, the territory belonged to them as
local men who were carrying on their investigations at their own
expense.
In connection with northern Georgia it may, however, be stated that
according to Dr. Lamartine G. Hardman, a member of the Georgia leg-
islature, a condition exists in Jackson County, Ga. , which corresponds
to what I found in Kershaw and Lancaster counties, S. C.
Macon, JSM County. Through the kindness of the local physicians
1 was able to examine two white orphan asylums in Macon.
In one of these, Dr. Clark (consulting physician) and I selected from
among the 85 children 17 boys and girls for closer examination. The
selection was made in the same manner as at Charleston, namely,
because of the pale, weak, or otherwise poor condition". Microscopic
examination showed 12 cases of infection with Uncinaria americana,
2 cases of infection with Hymenolepis nana, and 3 negative cases. The
uncinariasis cases came from sandy districts, namely: Americus, Sum-
ter County, 1; Buena Vista, Marion County, 2; Thomasville, Thomas
42
County, 1; Savannah, Chatham County, 1; and Waycross, Ware
County, Ga., 1; and Wacissa, Jefferson Count} 7 , 1; De Land, Volusia
County , 4; and Liveoak, Suwanee County, Fla., 1. Both Ilymonelepis
cases came from Georgia.
At another orphan asylum, through the kindness of Dr. Little, the
consulting physician, I examined 112 white children, all from Georgia.
I selected 21 for closer study, and the microscopic examination of the
feces revealed 17 cases of infection with Uncinaria americana, 1 light
infection with Hymenolepis nana, and 2 negative cases, 1 of which was
doubtless malarial. The 17 cases came from the following places:
Baxley, Appling County, 1; Cordele, Dooly County, 1; Darien,
Mclntosh County, 1; Effingham County,!; Johnson County, 1; Jones
County, 4; Kinderlou Station, Lowndes County, 1; Lyon, Tattnall
Count} 7 , 1; Monroe County, 1; Richwood, Dooly County, 2; Sanders-
ville, Washington County, 1; Waycross, Ware County, 2.
Four cotton mills were next inspected, some of the houses of the
factory hands were visited, and about 25 or 30 cases of uncinariasis
were found. Inquiry developed the important facts that the infected
persons had come to the mills from the rural sand districts, and that
in general their condition improved with their residence in the city.
An examination of the premises, both of the mills and of the houses,
did not indicate that the disease would spread.
At a negro school in Macon I failed to find a single case of uncinari-
asis .which could be diagnosed symptomatically with even a semblance
of confidence. In one case only did I even suspect the disease.
" Circus day " brought thousands of people into view on the streets,
many coming in from the surrounding country. Several cases of
probable uncinariasis were observed among the whites, but none
among the negroes.
Besides the Macon physicians mentioned above in connection with
the orphan asylums, I am under obligations to Dr. A. M. Burt, and
especially to Dr. H. McHatton for their cooperation in my work.
Milledgeville, Baldwin County. Through the kindness of Dr. T. O.
Powell, superintendent, and Dr. M. L. Perry, pathologist, of the
State sanitarium, I was able to see a large number of the patients.
Extreme cases of anemia were conspicuous by their absence. Two
patients were selected as possible cases of uncinariasis, the micro-
scopic examination being left in the hands of Dr. Perr} 7 , who has
kindly written me that it was negative.
Fort Valley, Houston County. With the cooperation of Dr. M. S.
Brown, a local physician, I found about 10 cases of uncinariasis near
town within an hour's time. The clinical histories were so typical
that it was considered scarcely necessary to make a microscopic exam-
ination; nevertheless this was done in one case with the result of
finding a severe infection with Uncinaria americana. After seeing
the class of cases I desired to find, Dr. Brown assured me that they
43
were common in that region, and that he could easily find 50 or
more cases within a day's time.
Albany , Dougherty County. Leaving the sand district I next visited
Albany, which is surrounded by c\&y. Corresponding to the change
in the soil there was a change in the medical facies. Uncinariasis
disappeared, except for cases which came in from the neighboring
sand districts, while malaria increased. Dr. Hilsman, one of the local
physicians, kindly drove around with me to find cases, but we were
obliged to go about 15 kilometers (9 miles), namely^ into Lee County,
before we located a family with uncinariasis. During this drive we
left the clay soil and passed into a sand district, with pine woods.
The family in question presented four typical extreme cases; although
microscopic examination for sake of diagnosis seemed unnecessary it
was nevertheless made and showed heavy infection with Uncinaria
americcma.
While with Dr. Hilsman in Albany I made a most fortunate mistake
in diagnosis. The patient was a boy about 13 or 14 years old. He
had a clear case of malaria (typical history, enlarged spleen, etc.), but
in addition to that I was confident that he had a medium or light
infection with uncinariasis. Microscopic examination proved me in
error. This boy lived in a clay district and had never lived in sand;
furthermore, he did not show the eye symptom, which I shall discuss
later (see p. 65). This is the last time I attempted a definite diagnosis
upon symptoms of any medium or light case unless severe cases
occurred in the same family.
As soon as Dr. Hilsman understood the kind of cases I desired to
see he stated, with the utmost positiveness, that they did not arise in
and around Albany until the sandy soil was reached. Occasionally
cases came to Albany from the neighboring sand counties, but the
local anemia Dr. Hilsman considered to be almost entirely of malarial
origin an opinion in which I can only concur after what I saw in
that city.
I happened to be in Albany on Saturday, when the country folks for
miles around come to town. Standing on the street corner for several
hours, I must have seen about 200 whites and fully 3,000 negroes who
drove or walked into town. Of the whites, I noticed about 5 cases of
probable uncinariasis. Two of the cases, whom I was able to inter-
rogate, gave a typical history of uncinariasis extending back for several
years, but no history of malaria. They came from neighboring sand
counties. Among the 3,000 negro men, women, and children, whom
I saw, there was only one person in whom 1 even suspected from his
general appearance that uncinariasis might be present.
WillacoocJiee, Coffee County. In southern Georgia, Coffee County
bears the reputation of being more or less a center for dirt-eaters. It
is a sandy, pine-wood district, with numerous swamps, which indicate
a more impervious subsoil. As a result, both malaria and uncinariasis
44
were found, and it was exceedingly interesting to note the ease with
which an error in diagnosis in medium and light cases could be made
if the microscope were not used. Extreme cases, however, could be
easily distinguished without the microscope. Several cases of typical
extreme uncinariasis were seen on the street, but not examined care-
fully. Then, through the kindness of Dr. Wilcox, I was able to make
a careful examination, both physical and microscopic, of a group of 8
cases at the sawmills a short distance from town. After Dr. Wilcox
examined these cases with me, he declared that he knew of at least 200
similar patients within the territory of his practice. He considered
this condition one of the most common diseases of that region, but
thought malaria was fully as common if not more so.
Way cross, Ware Comity. Passing now to Way cross, I entered a dis-
trict where uncinariasis is exceedingly common. Drs. R. P. Izlar and
J. L. Walker assured me that the cases I was tracing, two of which
1 saw with Dr. Walker, were much more common than was malaria,
the proportion being about 20 to 1. In this district these patients are
called "Branch- water people." Both Dr. Izlar and Dr. Walker stated
that they could easily show me scores of cases within a radius of a few
miles.
FLORIDA.
Jacksonville, Duval County. In Jacksonville two cases of typical
uncinariasis were seen on the street. One of these patients was traced
to the county in which the boy had formerly lived.
Both the State and the city health offices assured me that the condition
I was hunting was perfectly familiar to them that it was prevalent
throughout the State, especially in the "flat-woods district," and that
Florida physicians interpreted it as an anemia due to malaria and
improper diet.
Waldo, Alachua County. Through the kindness of the local phy-
sician, Dr. J. W. Boring, 1 was able to examine two groups of typical
cases of uncinariasis within a short distance from town. Dr. Boring
assured me that this condition was exceeding common in Florida and
was generally interpreted as an anemia due to malaria and improper
diet.
Ocala, Marion County. In Ocala I saw several typical cases of
uncinariasis on the street, and, through the kindness of Dr. A. L. Izlar,
I was able to examine 5 positive cases and 1 probable case more
closely. Dr. Izlar confirmed the statements of the health offices in
Jacksonville, Fla., relative to the frequency and interpretation of the
disease.
From Ocala I returned (November 16) directly to Washington, D. C. ,
and noticed several cases which presented the appearance I had found
typical of uncinariasis, as the train stopped at various stations in
Florida.
45
SYMPTOMATOLOGY OF UNCINAIUASIS.
In connection with the symptoms, let us recall that uncinariasis is
caused by hookworms about half an inch long which live in the small
intestine for several meters below the stomach.
These worms fasten to the mucosa and suck blood. They lay
numerous eggs, which can be found by a microscopic examination of
the stools. The number of eggs in the feces and, in a general way
also, the severity of the symptoms will vary with the number of para-
sites present and with the duration of the infection.
The injury to the patients results from the following factors: (1)
Sucking of blood by the parasites, which is a constant drain on the
system; (2) loss of blood into the intestine through the minute wounds
made by the parasite, a factor which also tends to deplete the system;
(3) the wounds form points of attack for bacteria, hence increase the
chances of bacterial infection as well as of toxic infection from partly
digested and decomposed food; (4) the wall of the duodenum and
jejunum becomes thickened and degenerated, and its function is thus
decidedly interfered with; (5) the parasites in all probability produce
a poisonous substance which acts upon the patient.
Theoretically there is only one sign which is present in every case,
namely, the presence of one or more parasites in the intestine. If
a This discussion of symptoms will be influenced to no slight degree by the fact
that during my trip my associates have been almost entirely practicing physicians,
particularly in rural districts, rather than laboratory specialists; and, since it is more
particularly the country practitioner whom I desire, to reach by this paper, I shall
not hesitate to use vernacular names even if these do not invariably have a classical
origin.
My trip was undertaken in order to prove the frequency and geographic distribu-
tion of the parasite, not to study the symptoms it causes. It was therefore a zoologi-
cal, not a clinical, trip, and on this account a zoologist, not a clinician, undertook the
investigation. Not posing in any sense of the term as a clinician, I feel that any
observations which I have made upon symptoms, sensu stricto, should be looked
upon as over and above the amount of work which should be justly expected of me.
Certain symptoms I could not help noticing. The circumstances of my trip, the
rapid travel, short stops, and the fact that the work was done among strangers, and
usually in the field instead of in a hospital, absolutely excluded certain observations,
even had I considered that I was the proper person to make them.
If, therefore, the reader misses in this discussion observations on any particular
symptom in which he is especially interested, I beg that he w y ill recall that it is self-
understood that the finer points in symptomatology must be studied by expert
clinicians.
I regret that it is not feasible for me at the present time to review the entire medi-
cal literature on uncinariasis. Such an undertaking would involve an unjustifiable
delay in sending much-needed information to physicians in the infected district.
In connection with my own observations, however, I shall make frequent refer-
ences to the noted paper entitled "Observations on 400 cases of anchylostomiasis,"
published in 1894 by F. M. Sandwith, M. D.. physician to the Kasr-el-aini Hospital.
Cairo, Egypt, thus supplementing my description with the views expressed by a
trained clinician.
46
these worms are in an egg-laying stage ova will be found in the
feces. But from a practical standpoint, severe cases present what
seems to be a characteristic type, and even medium cases often present
a more or less typical clinical history.
The statement is not infrequently made that there is one way and
only one way to diagnose a case of uncinariasis, namely, by examina-
tion of the stools to find the parasites or their eggs.
Academically this statement is more or less correct, yet practically
FIG. 42. A severe case of hookworm disease observed in Florida. Note the bloated face, the drooping
shoulders, the prominent abdomen, and the thin arms and legs. This girl is about fifteen years
old. Original, from a kodak photograph.
it should be somewhat modified. Sandwith (1894, p. 13), to quote
from a clinician, states that "fades of the patient is characteristic,
though it is difficult to describe his discontented, harassed expression,
which sometimes changes to a ready smile after a month's stay in a
hospital. " The data at my disposal would lead me to divide the cases
of hookworm disease I have observed into three general but not very
sharply defined classes, namely:
(1) Light cases, including those in which practically no distinct
symptoms of the disease are noticed, but in which a few hookworm
47
eggs are discovered in the stools. We may also place here a number
of cases in which, in addition to the presence of eggs, there is a slight
diarrhea or some other slight symptom, including more or less rapid
exhaustion after physical exertion, hence an indisposition to work,
which is usually interpreted as laziness. Cases of this class are found
in the infected areas and elsewhere, since infected people may move
away from the sand districts.
(2) Medium cases, including those in which the disease has progressed
to such an extent that a more or less anemic condition is noticed, but
other symptoms are not especially marked. If these patients were
found outside the infected area, the diagnostician (especially if he is
not familiar with the disease) would probably not see anything par-
ticularly characteristic in them; many of these cases, however, show
a more or less typical history, and if a history of residence upon
sandy soil in tropical or subtropical regions can be obtained, uncina-
riasis should certainly be strongly suspected. If these cases occur in
a family which also presents severe cases of uncinariasis, the diagnosis
of hookworm disease in the medium cases is usually quite safe, even
if a microscopic examination is not undertaken.
(3) Severe cases, in which we find that striking set of symptoms
which even the laity in our Southern States attributes to "dirt-
eating." These patients present a facies which is well recognized by
Southern physicians. If the patient is found in a Southern sand area,
the diagnosis is practically certain. If found outside of the infected
area, with a history of previous residence in a Southern sand district,
its recognition symptomatically ought not to be attended with diffi-
culty. In case of doubt, if a microscope is at hand, the test may be
made in less than five minutes; if no microscope is at hand, the blot-
ting paper test (see p. 81) will usually suffice.
Turning now to an analysis of symptoms, I will give my observa-
tions on the severe cases. It is needless to state that the symptoms
discussed may vary in intensity, and that not every symptom men-
tioned is found in every severe case. We find on the contrary an
imperceptible gradation between the severest and the lightest cases.
GENERAL PREDISPOSING FACTORS.
INFECTION OCCURS CHIEFLY ON SANDY SOIL.
In connection with the clinical history, the residence on sandy soil
is undoubtedly one of the most important points to be obtained. If
an anemic patient gives no history of temporary or permanent resi-
dence on a sandy soil, uncinariasis is not absolutely excluded, but
according to my experience the chances are against it. If on the
other hand a history of sojourn or residence in a sandy rural district
is obtained, the probabilities of uncinariasis are decidedly increased.
48
Nearly every case of the disease found during the entire trip was
either living at the time in a sandy district or had lived in such a place
a few years previously. As soon as I entered the sandy areas, uncina-
riasis was found. As soon as I left the sand, as at Albany, local foci
of infection of uncinariasis disappeared.
Inquiry among physicians at first failed to elicit any definite state-
ment regarding the soil on which anemia was most frequent, but upon
going farther south several physicians were met whose experience
fully confirmed my observations on this point. One physician in par-
ticular, Dr. A. M. Burt, of Macon, was of the emphatic opinion that
in bringing the condition which 1 have interpreted as uncinariasis into
connection with the sandy soil, I had found the keynote to the distri-
bution of the entire disease. Dr. McHatton, of Macon, called my
attention to the fact that in antebellum days the slave owners in the
Lower Mississippi Valley frequently provided special quarters, which
were removed from the sand districts, and to which they sent the
dirt-eating and other sick negroes and also negresses about to be con-
fined, the view being held that a clay soil was more salubrious than a
sandy soil. This view, in fact, I found to be rather prevalent among
the farm hands. Time after time they remarked, " We were never sick
so long as we lived in a clay district," "This disease developed after
we moved upon sand," etc.
This view that uncinariasis follows the sand is supported by evi-
dence obtained in Alaska by Mr. F. A. Lucas. After the discovery
was made that uncinariasis, caused by Uncinaria Lucasi, was preva-
lent among the seal pups, Lucas (see above, p. 39) showed that it was
practically only the seals on the sandy rookeries which were infested
with the parasites.
As stated above (p. 39), I have also observed two outbreaks of
uncinariasis among sheep and goats, caused by Uncinaria trigonocephala
(Rudolphi, 1809) Ralliet, 1900, on more or less sandy soil, and have
further confirmatory facts in connection with one outbreak of the
disease among dogs. Since returning from my trip I have found
at least one reference in literature on uncinariasis and ground itch to
the effect that the soil in districts where certain cases have occurred
was more or less sand}^ (see p. 62), but I have not yet found that any
author lays stress upon this point.
In view of all the data at hand, I have no hesitation in expressing
the opinion that uncinariasis, caused by Uncinaria americana, is pre-
eminently a disease of sandy localities and that cases found in clay or
rocky areas can usually be traced to a former visit or residence in a
sandy place.
Just why this disease should follow the sand rather than the clay is
not absolutely clear. Three explanations have occurred to me as
working hypotheses which, though not absolutely satisfactory as final,
will, 1 believe, explain part of the mystery.
49
(1) We know that uncinariasis is spread through the feces; we know
further that when the embryos hatch from the eggs they leave the
feces and enter the surrounding water or moist earth, while there is no
satisfactory evidence to show that they are blown around in the air in a
dry state. (See Stiles, 1902b, p. 199.) Now, assume that a person walks
over infected ground; if that ground is clay, he does not disturb the
embryos which have crawled beneath the surface, except in wet places;
if, on the other hand, the ground is sand, he not only stirs it up while
walking, thus bringing the young worms nearer the surface again and
thereby increasing their chances of producing an infection, but he is
also likely "to carry away particles of sand, together with embryos,
with him on his shoes or feet, thus increasing his chances of becoming
infected. It is further clear that children playing in sand will stir up
more embryos than when playing on a clay soil, and will thus increase
their chances of infection.
(2) An additional explanation is that water will not pass through clay
as it will through sand; hence on clay soil the embryos stand a greater
chance of perishing or of being washed by rain into the streams. On
sand, however, the embryos might perhaps work their way through
the soil a with the water, and thus infect surface wells. In advancing
this hypothesis, I am not unmindful of the view, supported by excel-
lent observers, that, since the embryos sink in water, drinking water
is not necessarily a common source of infection. Granted that they
do sink in water, a water bucket in a well also sinks, and the water
from surface wells frequently contains sand particles that are heavier
and larger than Uncinaria larvae; hence we can not altogether ignore
the drinking water as a possible source of infection. If, on the other
hand, drinking water were the only source of infection, it is probable
that in families where uncinariasis exists the intensity of the disease
would show a greater tendency to uniformity.
Giles has examined 56 specimens of water from wells and ponds of
villages affected with hookworm disease and 16 of these he found by
chemical and microscopical examination to be u bad" or "very bad."
Yet on only one occasion did he find a rhabdite of doubtful origin in
water. (Sandwith, 1894, p. 9.)
(3) Oxygen is necessary to the development of the embryos and
larvae, and it does not seem unreasonable to assume that sand would
In an article which has just appeared, Looss (1903, p. 331) says:
" Further, during the six years of my residence in Cairo [Egypt], I have not heard,
up to the present time, of a single case [of hookworm disease] in an European (my
own case, of course, excepted). This fact speaks all the less [so much the less] in
favor of the assumption of a more common dissemination [i. e., infection] of the
disease through the drinking water, vegetables, etc., since [as] the mature hookworm
larvx, as experiments have shown, pass through the ordinary sand filter with surprising
rapidity, and this even when the water is allowed, not to run off, but to stand." [Italics
not in the original German.]
19558 No. 1003 4
50
on that account present more favorable conditions for the growth to
the "encysted stage, and probably also a longer preservation of that
stage.
In this connection it may be noted that Looss has used charcoal as
a medium in which to cultivate the larvae of Agchylostoma duodenale.
INFECTION OCCURS CHIEFLY IN THE RURAL DISTRICTS.
Since the infecting agent of uncinariasis is spread through the f eces,
we may expect to find infection taking place (other, things being equal)
in localities where the fecal matter is not properly disposed of. Fur-
thermore, we would not expect that paved streets or grass lawns
would favor the development of the disease. We need not therefore
expect local foci of infection to occur in cities and towns which have
proper sewerage systems and in which the streets and walks are paved
and the yards sodded; but we may expect to find local foci of infec-
tion in localities where box privies are used but not properly cared
for, or where promiscuous defecation occurs in the woods, fields, mines,
etc. This condition is in fact exactly what is found. While unci-
nariasis is not entirely absent from those premises on which the feces
are properly disposed of, in cities like Washington, Richmond, Charles-
ton, Macon, Jacksonville, and Ocala, such cases as are found can not
be shown to have developed there; but probably in most every case
they can be either probably or positively shown to have been con-
tracted elsewhere. In a number of cases I have established this point
with a probability, which for all practical purposes may be looked
upon as a certainty. We may therefore exclude the greater portion
of the inhabitants of sanitary districts of cities from consideration in
connection with uncinariasis and may with confidence lay down the
general rule that any anemia developing in them as result of local
infection (namely infection at home) is much more likely to be due to
malaria or other causes than to uncinariasis.
As we approach the outskirts of cities and towns and enter the rural
districts, localities in which box privies are used but not always prop-
erly cared for, we meet with' conditions which are more favorable to
infection with the hookworm disease. Accordingly, in cases of anemia,
especially in women and children, developing in such localities, unci-
nariasis must be taken into consideration as one of the possible causes.
Sandwith (1894) states that his patients came from all parts of Egypt
except some of the seaport towns.
As we go into the country and visit the farms we not infrequently
find a condition, in respect to the disposal of fecal discharge, which
almost beggars description. Taking the rural districts visited during
my recent trip as example, it is not an exaggeration to say that with
the exception of the planters' premises, not over half of the country
houses or huts of the sand regions have any privy at all; if there is
51
one present, it is rarely properly cared for; furthermore it is the excep-
tion rather than the rule that it is used. As a result uncinariasis is
widespread, not because the country air is particularly favorable to
its development, but simply because so little attention is paid to the
proper disposal of the fecal discharges.
SYMPTOMS ARE MORE SEVERE IN SUMMER THAN IN WINTER.
It is almost universally conceded that the patients are in better con-
dition in winter than in summer. According to testimony, the symp-
toms begin to increase in the spring and to decrease in the early winter.
This periodicity will be noticed, of course, only in localities which are
above the frost line, and it is easily explained when we take into con-
sideration the biology of the parasites. Cold retards and heat hastens
the development of the eggs and the embryos; a freezing temperature
of 24 to 48 hours' duration, it is said, kills both eggs and embryos.
Accordingly, after frost sets in in the fall, the patients will add less to
the infection which is present in their bowels than they will during the
summer. Some of the worms already in the intestine will be passed,
thus decreasing the number of parasites present; the patient will
accordingly lose less blood and will on this account feel somewhat
better. As warm weather begins in the spring the free eggs and
embryos will develop more rapidly and the infection will be increased.
There will be more parasites in the intestine, hence symptoms will be
augmented.
Some few patients, however, insist that they are better in summer
than in winter.
It is probable that the seasonal periodicity of the symptoms noticed
in our Southern States will be modified in the Tropics, so that the
symptoms will increase in severity in the rainy season and decrease in
the dry period of the year. Such a periodicity would correspond to
the biologic fact that the eggs and embryos perish very quickly upon
becoming dry.
In patients who are not subject to continued infection, as for
instance those who have left the area of infection, the seasonal
periodicity may be expected to disappear.
WHITES APPEAR TO BE MORE SEVERELY AFFECTED THAN NEGROES.
Osier and other observers have already noticed that chlorosis is more
frequent in blondes than in brunettes.
Uncinariasis occurs in both blondes and brunettes, and in both the
white and the negro, but so far as my observations go the disease is
more severe, or at least more noticeable, in blondes than in brunettes,
and much more severe, as a rule, in the white than in the negro. This
observation was supported by all the evidence I could gather from
local physicians. In fact, several practitioners declared that they had
never seen a case in the negro to recognize it. There is, however,
abundant evidence that such cases do occur.
52
I am at a loss for a satisfactory explanation of the comparative
freedom from uncinariasis noticed in the negro. They live under the
same conditions as the poorer classes of the white population, except
that, as a rule, the negro farm labor is more common in the rich than
in the sand districts; however, negroes also live in infected districts.
It is true, as frequently claimed, that some of the negro habitations
are more clean than some of the homes of the poorer whites. Still,
not all negro huts are cleaner than all white huts. The personal
habits of the negro children are certainly no more hygienic than those
of the white boys and girls.
One factor which may possibly play a role in this comparative free-
dom from the disease on the part of the negro is the fact that negro
women very frequently give their children "worm tea," made from
certain plants, in order to expel the " eelworm" (Ascaris lumbricoides),
or they give calomel " to regulate the liver," and this may perhaps
also result in expelling the hookworms before the latter have had an
opportunity to do much harm. Still this explanation is not altogether
satisfactory, especially in view of the testimony of both the local phy-
sicians and the negroes themselves to the effect that eelworms are
much less common now than formerly, hence "worm tea" is not
taken so frequently as in former years.
Chabert (1821a), Jordan (1832), Imray (1843), Le Conte (1845), Duncan
(1850), and other authors report "dirt-eating" among the negroes. In
fact, nearly all early authors who describe "dirt-eating" lay special
stress on the frequency of the habit among the slaves.
In conversation with a negro druggist, I was informed that while
dirt-eating was formerly said to be more or less prevalent among the
negroes, it was an acknowledged fact among them that the custom had
greatly decreased in recent years. In connection with this statement
we may note the interesting claim by Cotting (1836a) that there was a
reduction in dropsy and dirt-eating corresponding to the more general
use of calomel.
Sandwith remarks upon the apparent comparative freedom of the
negro from uncinariasis and anemia. Zinn and Jacoby (1896) also
refer to the frequent presence of Agchylostoma duodenale in negroes
of Africa, in whom the anemia was not prominent.
Can it be that the poison produced by the hookworms has less effect
upon negroes than on whites and that on this account the disease is
less severe in the dark races?
OCCUPATION OF PATIENT.
It is generally acknowledged by writers on uncinariasis that the
disease is especially prevalent among people who in their daily work
come in contact with earth. In fact, the malady is sometimes called
" brickmakers' anemia" or "miners' anemia." Sandwith mentions
"peasants" as apparently forming the majority of his patients.
58
In my own work I was surprised to find that hookworm disease was
comparatively light and comparatively rare among the miners I exam-
ined. Of brickmakers my statistics are too small to permit any gen-
eralization. Two examinations out of eight showed light infections.
Most of my cases were from the farming classes.
Sandwith emphasizes the fact that his patients came from the poorest
class of the community, and that of 200 men 190 were accustomed to
work with their hands in more or less damp earth. Of these 190 men,
152 were agricultural laborers; 18 were masons or bricklayers'
laborers; 7 were "scavengers of street refuse and of cesspools, accus-
tomed to emptying with their hands the dry contents of the latter;"
7 were peddlers of unwashed vegetables;. 3 limestone carters and scav-
engers; 1 gardener; 1 fisherman in the mud; 1 "shadouf " worker at
the Nile bank; 1 coffee-stall keeper; 3 readers of the Koran; 1 black-
smith; 1 shoeblack; 4 beggars. Sandwith also mentions 20 cases
among policemen, who dated their illness from periods of life when
working as agricultural laborers.
SEVERE CASES ARE MORE COMMON IN WOMEN AND CHILDREN THAN IN MEN OVER
TWENTY-FIVE YEARS OF AGE.
The assertion is frequently made that uncinariasis is more common
in men than in women and children. This statement may be perfectly
correct in mines and brickyards, but it does not hold good for the
farming localities I visited, where the greater prevalence of severe
cases in children than in adults, and in women and children than in
men over 25 years of age, is very striking. The conditions found, in
respect to this point, seem to be due to- four factors in particular,
namely: (1) The average family in the country districts numbers from,
say, 6 to 12. As a rule, 2 or 3 of these can be called adults, and
3 to 9 can usually be classed as children (including minor boys and
girls). Since there is a greater number of children than adults sub-
ject to infection, we should naturally expect to find a greater number
of cases among the children, and our expectations are fully realized.
(2) The fact that children and women present a greater number of
cases than do the adult males over 25 years of age I am inclined also
to explain on the ground that the former are at home more than are
the men; the area immediately surrounding the house, for, say, a radius
of 50 meters, is a more common place for defecation than are the more
distant fields, hence it is more severely infested with the infecting
agent. Now, while it is true that, among certain classes, both women
and children work _in the fields, it is also true that the} 7 do this much
less than the men. They are at home more, therefore they are on the
more intensely infected area for a greater length of time; hence, in
respect to actual time they are more subject to infection than are the
men, and, other things being equal, they will present a greater num-
54
ber and a greater proportion of extreme cases. (3) The children in
playing in the sand around the house, and owing to their more careless
personal habits, are of course especially liable to infection. (4r) The
men being stronger, are, as a rule, better able to withstand the effects
of infection. An interesting and important fact is that men of about
20 to 24 seem in many cases to more or less outgrow the effects of the
malady. They give a history of medium or severe infection from,
say, 10 to 18 years of age, then at 18 or 20 they begin to improve,
and finally appear much better, although their features and physique
still show the effects of former disease. This time of improvement
corresponds to the years following their first more active participa-
tion in work which takes them more away from the house, hence to
years when they are subjected less constantly to infection.
Sandwith states that nearly all of his 402 patients were in the prime
of life, between 20 and 40 years of age. His j^oungest case was a boy
of 6 years; 48 patients were between 10 and 20 years of age; 170
patients were between 20 and 30 years of age; 140 were between 30
and 40 years of age; 21 were between 40 and 50; 15 were between 50
and 60; and 7 were above 60.
Giles reports a case of a girl 4 years of age. My youngest patient
was 3 years old.
Of Sandwith's 402 cases only 3 were females. This statement is in
striking contrast to my observations. Sandwith and I made our
studies, however, under totally different conditions, for his patients
came to his hospital, while I went to the homes of the infected persons.
Possibly this will explain, in part, our different results, for he states
that u women have not yet learned to apply for hospital relief in the
same proportion as the men."
SEVERAL CASES ARE LIKELY TO OCCUR IN THE SAME FAMILY. *
Uncinariasis commonly occurs in groups of cases. If one child in a
family is accused of being a "dirt-eater," and is shown by physical
and microscopic examination to represent an extreme case of unci-
nariasis, an examination of the remaining members of the family will
usually show that most or all of them are suffering from anemia in
different degrees, and the microscope will disclose infections with
Uhcinaria. This condition of affairs is so general that it may be
looked upon as the rule among farming classes, while the occurrence
of isolated cases in a family, except possibly among- miners, may be
looked upon as the exception. Numerous observations could be cited
in support of this view; for instance, in the first family examined in
the sand district near Haile Goldmine only one member had the repu-
tation of being a '"'dirt-eater," but all 11 were in different stages of
anemia. In a family of 10 members on a neighboring plantation only
1 was noted as a resin-chewer, but all 10 were anemic. In orphan
55
asylums it was noticed that if two or more children of one family
were present and one child was affected, the other children were also
affected. In fact, in every instance where I was able to examine the
family to which an alleged " dirt-eater" or " resin chewer " belonged,
all or nearly all the members of the family showed an anemia with the
general history of uncinariasis, and in every case examined micro-
scopically the eggs were found.
Two families may, however, live very close together, and one family
may show several severe cases while the other may not show a single case
severe enough to be suspected symptomatically. Thus, on one planta-
tion all the hands examined showed uncinariasis, while the planter's
family, of much more cleanly personal habits, did not exhibit any
signs of infection. It is, however, more common to find that where
one family is affected other families of the same neighborhood will
show infection, provided of course that the infected family in ques-
tion has not moved into a city or a clay district.
The occurrence of cases of uncinariasis of different degrees of
intensity in family or neighborhood groups is easily explained by
the fact that in a given family or neighborhood all persons are subject
to the same general conditions of infection, but owing to differences
in age, daily occupation, personal habits, etc., some will be more
subject to infection than others.
OBJECTIVE AND SUBJECTIVE SYMPTOMS; ANALYSIS OF SYMPTOMS.
It is difficult to draw a distinct line between the subjective and the
objective symptoms. If a patient is left to tell his own story, prac-
tically all that the observer will learn is that the patient "feels weak,
has a headache, gets dizzy, has fluttering of the heart, finds it hard to
breathe, feels worse in summer than in winter, and has 'misery' in the
'stomach." In medium cases a few judicious questions, directed
more to the parents than to the patient, will as a rule bring to light a
history upon which, taken in connection with what one can himself
observe, a probable diagnosis may be made. As a rule, little weight
can be placed upon the statements made by a patient suffering from
an severe infection of uncinariasis. He will answer "yes" or "no"
in a most contradictory manner, so that by putting questions in differ-
ent ways it is practically possible to make him admit or deny, as
desired, any particular symptom. It is chiefly from the patient's
family that one must judge of what the person has complained.
ONSET AND INCUBATION.
As it takes the parasites four to six weeks to reach maturity after
entering the system, the earlier symptoms will be more particularly
gastro-intestinal (see, however, p. 60), and even if these are present in
a marked degree we can not look for a diagnosis by microscopic
56
examination of the feces until the worms begin to lay eggs. It is,
however, not excluded that some of the } r oung worms might be passed
in the stools and be identified, though such a chance is probably
more theoretical than practical. In an experimental case of infection
through the skin, Looss showed that eggs did not appear in the feces
until 71 days after infection. According to Sandwith (1894, p. 12),
Surgeon-Major Giles suspected that many of his patients in Assam had
suffered from fever at the onset of their malady, and he was confirmed
in this impression by observing pyrexia in the monkeys fed on hook-
worm embryos.
Looss (1897, pp. 914-915) noticed nausea as the first symptom in
dogs to which he fed the larvae of Agchylostoma duodenale.
Bentley (1902 a) practically advances the view that "ground itch" is
the primary symptom, and since Looss's view of infection through
the skin is correct, at least for some cases, some cutaneous symptom
must in such instances be the first symptom of uncinariasis. (See
p. 60.)
STAGES OF UNCINAKIASIS.
Since my observations of each patient were confined to one or two
days, they would not justify me in dividing the disease into stages.
Lutz (translated by Macdonald) recognized the following stages:
I. STAGE OP PURELY LOCAL SYMPTOMS.
(a) Acute form; (6) chronic form. The symptoms are similar in both forms. The
disease is yet limited to pains and disordered digestion; no pallor, no rise of pulse.
II. STAGE OF SIMPLE ANEMIA OR OLIGOCYTHEMIA (CHLOROTIC STAGE).
(a) Acute form. 1. Slight degree: Conjunctival vessels still visible; nails and lips
pale red; pulse increased in frequency; no blowing murmurs over cardiac area.
2. Higher degree: Conjunctive devoid of vessels; nails whitish; lips pale; pulse
frequently very much increased; no blowing murmurs.
(b) Chronic form. Anemia has not reached the highest degree. In many cases
distinct cardiac hypertrophy and dilatation; in other cases disordered valve closure;
seldom both combined. Moderate increase of frequency of pulse.
III. DROPSICAL STAGE.
(a) Acute form. A high degree of anemia; pulse small, much increased in fre-
quency; no blowing murmurs; edema of a hydremic character.
(b) Chronic form. Symptoms of ca-rdiac defects, with disturbed compensation, or
of fatty degeneration; distinct symptoms of cyanosis; dropsy of engorgement;
anemia of varying intensity; disordered nutrition.
DURATION OF UNCINAKIASIS.
In speaking of the duration of uncinariasis, we should clearly dis-
tinguish between the duration of cases which remain in the infected
areas, and the duration of cases which after once becoming infected
move to uninf ested districts where conditions are such that reinfection
is excluded.
57
Tn the former instance we have to deal with cumulative infection,
taking place week after week and year after year, hence successive
generations of parasites come into consideration.
In the latter instance we have to deal with the individual life of the
parasites which are present in the patient at the time he leaves the
infested area.
A failure on the part of most observers to distinguish between these
two classes of cases renders the published data less valuable than they
otherwise would be in determining the duration of uncinariasis.
In my own observations, I have found people remaining in the
infested areas who gave a history of the disease extending back for
ten, twelve, and even fifteen years. I have further three observations
which I consider free from criticism in connection with patients who
presented the disease six years (2 cases) and even six years and seven
months (1 case) after being removed from the source of infection. I
also have one observation, which is not free from criticism, upon a
patient who showed the disease ten years after entering a hospital.
Sandwith (1894, p. 15) in discussing the duration of illness says
"Nearly every patient said he had been ill two or three years before admission.
I find among my notes 29 cases, uncomplicated by other diseases, where the patients
said they had suffered more than three years. Of these, 13 had been ill for four
years, 6 for five years, 3 for six years, 2 for eight years, 2 for nine years, 2 for eleven
years, and one vowed it was fifteen years since the commencement of his symptoms.
"It may be safely said that during these long intervals of time very few patients
had any rational treatment."
It is probable that Sandwith's cases were subject to cumulative
infections.
LENGTH OF LIFE OF THE INDIVIDUAL PARASITES.
It is already established that for ever} T hookworm which is present
in the intestine a separate embryo must enter the body. In other
words, the eggs which the female worm deposits in the intestine will
riot develop there to mature parasites, but must first be discharged in
the feces and undergo certain changes.
It is further clear that direct autoinfection, such as takes place in
the case of pinworms (Oocyuris vermicularis), is excluded. For
instance, suppose a child is at stool and soils his fingers with the
feces, which contain hookworm eggs, then puts his fingers into his
mouth and swallows the eggs; these ova will not develop in the
bowels into adult worms.
Whether an Uncinaria egg, which happened to get under the finger
nails, could reach the larval infecting stage in that place is perhaps an
open question. So far as 1 am aware, the point has nover been
studied, but what is already known about this group of parasites does
not lead me to believe that such a condition would be especially
common, although it does not seem absolutely impossible.
58
With the foregoing premises in mind, it is important to determine
how long the parasite in the intestine can live. Regarding the Ameri-
can hookworm, Uncinaria americana, I can present the following
data: Of children at the Charleston Orphan Asylum in whom I
demonstrated the presence of Uncinaria americana microscopically,
it may be noted that 8 children had been in the orphan asylum two
3 7 ears or less; 4 children had been in the asylum between two and three
years; 2 children had been in the asylum six years; 1 child had been
in the asylum six years and seven months.
I have selected the Charleston Orphan Asylum as best fulfilling the
conditions desired to illustrate the point at issue. The refined disci-
pline, the scrupulous cleanliness, and the general hygienic conditions
noticed are such that local infection is practically excluded. It must
be admitted that some persons coming in from the country might
possibly bring on their shoes a few embryos, but such a theoretical
possibility is altogether too remote to explain the 15 cases found.
For all practical purposes we are justified in assuming that the
hookworms which these 15 children had in them when I saw them
w T ere the same individual worms which were in the children when the
latter entered the asylum, and from the data obtained it is clear that
hookworms of the species Uncinaria americana are capable of living
six years and even six years and seven months.
A sixteenth child (case of L. B.) examined showed a clear clinical
history of uncinariasis of long standing. Her condition at the time
of entering the institution, as described to me by Dr. Huger, and her
present complexion, eyes, stunted growth, and inferior mental develop-
ment leave no practical doubt in my mind regarding the diagnosis.
No normal eggs were found in her stools, despite the fact that 1 made
25 slides. One slide showed a single abnormal egg which had evi-
dently been dried and had clung to the slide after an examination in
some other town. 1 do not know this girl's complete therapeutic his-
tory during the past twelve years, but from the absence of eggs in her
stools it is necessaiy to conclude either that the worms had been
expelled by the drugs taken or else Uncinaria americana is not able
to live twelve years.
Ashford(see Stiles, 1902b, p. 210) mentions a case where a boy "had
been the host of the worm for probably ten or fifteen years," but he
does not state that during this time the patient was not exposed to
further infection.
The clinical importance of the length of the life of the parasite is
self-evident. Suppose a physician in the North has an anemic patient,
or a physician in the South has an anemic patient who lives in the city
or in a clay district; it is not sufficient to inquire whether he or she
has recently been exposed to malaria, but inquiry should extend for
eight or more years back in order to develop the fact whether she has
59
during this time visited any tropical or subtropical sand area. If such
a fact does develop, uncinariasis is among the probabilities and a
microscopic examination of the feces should be made.
GENERAL EXTERNAL APPEARANCE.
GENERAL LACK OF DEVELOPMENT STUNTED GROWTH.
In severe cases of long standing the patient is undeveloped both
plrysically and mentally. A boy or girl 12 to 14 years old may be as
small as the average child of 6 or 8; a young man or woman of 18 to
22 years old may present the general development of a child 12 to 16
years of age, but the face may appear either like that of a child or
like that of a very old person, especially like that of an elderly dwarf.
Similar conditions have been described as a symptom of dirt-eating.
SKIN.
The skin has an anemic, waxy white to a yellow or tan, shriveled,
parchment-like or tallow appearance. In general it is that color
known in the South as a "Florida complexion." In some cases of
malaria, if one trusts too much to the appearance of the skin, he is
likely to be misled into an erroneous diagnosis of uncinariasis, but the
general clinical history is usually sufficient to distinguish between
the two diseases, while the microscopic examination gives a positive
diagnosis. (See also, Temperature, p. 72.)
Wounds heal slowly. Among the first severe cases of uncinariasis
found, I noticed that several of the patients wore bandages. Suspect-
ing the possibility of ground itch and recalling Looss's and Bentley's
theories (see below), I immediately inquired into the history of the
sores. According to the testimony of the patients the ulcers present
had started as small wounds produced mechanically; the wounds had
failed to heal promptly, had grown worse, and were now about a
year old. This same story was related to me by quite a number of
patients, and many other persons suffering from uncinariasis assured
me that in their cases cuts and bruises healed very slowly, testimony
which was repeatedly corroborated by local physicians.
Cutaneous lesions caused by uncinariasis. The statements- just made
lead to a consideration of certain views recently advanced by Looss
and Bentley.
Looss's theory of cutaneous infection. Looss (1901) has shown that
if a drop of water containing embryos of Agchylostoma duodenale is
placed upon the skin an itching sensation is produced; the worms
enter the hair follicles, and from there they seem to bore into the
surrounding tissues. Looss further advanced the rather startling
opinion that the larvae then reached the intestine, and he recounted
observations which gave a certain amount of plausibility to this view.
60
More recently (see Sandwith, 1902), Looss has performed experiments
which, so far as can be judged at present, demonstrate the correctness
of his theory. According to Sandwith (1902), Looss smeared on the
back of a puppy a mixture of charcoal and feces in which hookworm
larvae had been bred. Between nine and ten days afterward the
puppy died and was found to have anemia of most of his organs, and
a plentiful supply of young hookworms was found in his jejunum. A
second puppy was treated in a similar way and also died on the night
between the ninth and tenth days. Upon post-mortem he also showed
exactly the same results. A man who offered himself for experiment
was also similarly treated on his forearm, and in his case the first
hookworm eggs were discovered in his feces on the seventy-first day.
In all three experiments the feces were regularly examined for some
weeks prior to the experiments, so that, so far as we can now judge,
the results must be accepted, despite their very startling nature.
Furthermore, Looss is known as too careful an investigator to permit
any foreseen error to creep into his conclusion.
Somewhat similar results, namely the entrance of embryos into the
skin, have been obtained by van Durme (1902, pp. 4:71-474) in experi-
ments with Strongyloides stercoralis on guinea pigs, and it is needless
to insist on the great importance of Looss's demonstration.
Bentley* s theory of ground itch. In line with Looss's views, Bentley
(1902a) has made certain exceedingly important observations and
experiments, the logical conclusion of which, taken in connection
with Looss's work, seems to be that at least certain forms of ground
itch constitute the initial symptom of uncinariasis. Bentley defines
ground itch as follows:
Ground itch Synonyms: Panighao, water itch, water pox, water sores, sore feet of
coolies is an affection of the skin, confined entirely to the lower extremities, and
probably always associated with the presence of the larvae of Ankylostoma duodenale
in the soil of the affected areas; endemic in Assam and the West Indies and possibly
present in other parts of the Tropics; characterized by its periodical epidemic
appearance in the infected areas, coincident with the onset of the rainy season; with
typical lesions consisting in a primary erythema, followed by vesicular eruption,
which frequently becomes pustular and in severe cases may result in obstinate
ulceration, or even gangrene.
Dr. Seheult (1900), of Trinidad, has suggested that the disease is
probably due to some chemical irritant present in the soil, either
natural or due to manure used in cultivation. Dr. Dalgetty (1901), of
South Sylhet, struck by the resemblance which the lesions bear to
scabies, and finding a mite present which he named Rhizoglyphus
parasiticus, assumed this acarine to be the cause. These authors and
Bentley (1902a) seem to agree that ground itch is a filth disease which
During the proof reading of the present report, Looss's (1903) article, detailing
his brilliant experiments, has appeared. He demonstrates, beyond any question of
a doubt, the correctness of his contention that infection with hookworms may take
place through the skin.
61
is increased by the lack of care given to the proper disposal of alvine
discharges.
Bentley (1902a) found in a water sore a young worm which he con-
sidered to be identical with Agchylostoma duodenale. He then per-
formed the following experiments
(/. Some ordinary soil was sterilized by. heat, and after being
moistened with sterilized water, was infected with a small quantity of
fecal matter containing numerous ova of Agchylostoma duodenale.
1). A similar preparation of soil was infected with a small quantity
of f eces, which on examination was found to be free from -hookworm
infection.
These two preparations were incubated at the ordinary temperature
of the air for about a week, when sample "" was found to be swarm-
ing with larval hookworms and various forms of bacteria and fungi,
and sample u 1) " was similar in appearance except that no hookworm
[larvaB were found.
1 Each sample was then divided into two parts, a' and a" and b' and
1)" . Samples a' and ft were kept moist, while a" and b" were gently
dried by exposure to the air for eight hours. Previous experiments
had shown that six hours gentle drying at ordinary temperatures was
sufficient to kill the hookworm larvae. After remoistening a" and b"
with sterilized water, the four samples were applied to the wrists of
the subjects of experiment for eight to nine hours, and then they were
removed. Fifteen hours after the first application, considerable ery-
thema with a minute papular eruption appeared over the spot to which
a' had been applied; within twenty-four hours a distinctly vesicular
eruption had developed, followed by pustules exactly resembling those
found in the lesions of ground itch. In the other cases a faint redden-
ing of the skin was produced, which shortly afterwards disappeared.
A reexamination of sample a 1 now showed that no live larvae were
present, although one or two dead worms were found. Sample a"
still contained the dead larvae. Apparently, therefore, the live larvae
I a' had entered the skin and their entry had been followed by lesions
similar to those found in water sore.
According to Bentley, also, it is probable that the acuteness of the
inflammation attending an attack of the ground itch is largely governed
by the nature of the organisms which accompany or follow the larval
hookworms in their passage through the skin.
Regarding the treatment of ground itch, Bentley says that in the
papular and early vesicular stage of the disease the application of a
strong solution of salicylic acid in collodion or methylated spirit will
cause the eruption to dry up, and so cut short the attack of the disease
to one or two days. If, however, pus has formed, the only treatment
\ of any service is the opening up and disinfection of the pustules with
pure carbolic acid, silver nitrate, or nitric acid, and the after treatment
of the sore as an ordinary ulcer. In cases attended with great swell-
62
ing, inflammation, and tendency toward the formation of sloughs, free
skin incisions and the use of hot antiseptic footbaths are indicated.
Dalgetty (1901, p. 77) advises the application of a strong solution of
lime and sulphur; strong phenyl solution is also beneficial, and a coat-
ing of coal-tar acts for a time as a preventative against infection; but
when once the vesicles have formed pustules are sure to follow, and
then the only remedy is to open them, evacuate the pus,- and thoroughly
cleanse them.
An anonymous writer (? Dr. Elliot, of Assam) in the Journal of
Tropical Medicine (1900), gives the following directions:
" The indications are to get the case as soon as possible; to carefully cleanse the foot
by soaking it in warm antiseptic solution; then open the vesicles with sharp pointed
scissors, snip the loose skin away, and finally wash the parts with carbolic acid solu-
tion (1 in 40), and treat the resulting ulcer with carbolic acid, phenyle oil, extract
of paroli leaf, zinc ointment, etc., according to circumstances. The soaking, wash-
ing, and dressing operations are repeated once or twice daily, and healing takes place
in eight or nine days in favorable cases."
It will be noticed that Bentley does not definitely state that he adopts
Looss's view of intestinal infection through the skin; nor does he defi-
nitely state that the hookworm larvae act as anything more than carriers
of bacteria. The conclusion would therefore seem to be that the ground
itch with which he was dealing is a bacterial infection due very prob-
ably to fecal bacteria. a If this interpretation is correct, its dependency
upon uncinariasis does not seem to be proved, although its occurence
with the disease would seem to be established.
Additional facts (besides Bentley's experiments) which support
the view that the ground itch, with which he was dealing, is more or
less connected with hookworm infection are the following:
Ground itch occurs in the warm rainy season, especially in June,
July, August, and September, and does not occur in cold weather,
even when it rains; thus the seasonal distribution in general agrees
with the infection period of uncinariasis. Grass-covered soil and
smooth beaten roads do not cause it, neither does working in loose dry
soil; and these conditions are unfavorable to the development of
uncinariasis. The number of cases increases after a heavy rain and
rapidly decreases during a hot spell, a fact which agrees with the
biology of hookworms. " The soil itself is sandy, with clay here and
there; a belt of pure sand, 40 to 60 feet thick, lies at a depth of 6 to
18 feet from the surface;" and uncinariasis is preeminently a sand
disease.
Still the question is not quite so simple as would at first appear, and
in connection with the subject the following points come up for con-
sideration :
^Looss has, however, proved that certain cutaneous symptoms follow the entrance
of hookworm larvae into the skin.
63
1. According to Bentley, ground itch is confined entirely to the
lower extremities, and other authors state that it rarely extends above
the ankles. According to the physicians in Georgia and Florida, it is
found on other parts of the body also. I saw one case, said to be
typical, where the disease was confined to one arm. Under these
conditions is the panighao, discussed by Bentley, identical with the
so-called " ground itch" which is so common in the southern portion
of the United States, or is only a part of the American " ground itch"
produced by hookworm larvse?
2. If ground itch is the initial stage of cutaneous infection with
uncinariasis (as Looss's and Bentley 's views would seem to indicate),
why should it be confined entirely to the lower extremities? If
infection by uncinariasis frequently takes place through the skin,
would not the hands and arms also, especially of children, and more
particularly the soles of the feet and the palms of the hands, the
spaces between the toes and fingers, and under the toe nails and finger
nails, be the most common initial points of ground itch in case this
latter is an initial symptom of uncinariasis ?
3. On the same premises would we not commonly find lesions corre-
sponding to ground itch on the abdomen of cattle, sheep, goats, dogs,
cats, foxes, seals, and other animals suffering from uncinariasis? I
will not deny that such lesions occur, but I have seen many cases of hook-
worm disease in certain of these animals and I have no recollection of
having observed anything which corresponded to ground itch. If it
were as prominent, in the animals named, as the typical "ground itch"
of man which I saw in Georgia, I doubt whether I should have over-
looked it. Possibly I did not have recent infections before me.
4. According to the testimony of Georgia and Florida physicians
"ground itch" is exceedingly common; it occurs at some period in the
life of practically every person, unless he lives exclusively in the city;
it occurs in the healthy as well as in the sickly, and in persons who
neither at the time of infection nor later show the slightest evidence
of anemia. These statements, which I have repeatedly heard from
Southern physicians, can not be said to indicate that Bentley's views
are applicable to all cases of "ground itch" as we find this disease in
this country.
5. "Ground itch" is said to be common in clay districts as well as in
sand districts. Under these circumstances, why is uncinariasis so pre-
eminently a disease of the sand areas ?
6. Bentley states that "ground itch" is probably always associated
with the presence of the larvae of Agchylostoma duodenale in the soil
of the affected areas. Doubts may, however, arise as to whether a
sufficiently wide geographic range has been examined in connection
with this point.
In view of the above considerations, it will be well to remain open
64
to conviction awaiting a more thorough demonstration of the broad
application of Bentley's interesting and valuable views. But until
better proof is advanced than has thus far been brought to m}^ atten-
tion, I find it impossible to unreservedly adopt the opinion that Amer-
ican ground itch is necessarily connected with uncinariasis.
While not opposing the theory of infection through the skin, but
admitting, on the contrary, that Looss has proved his point, I
may state that the conditions which I saw in the southern portions
of the United States do not indicate that any indirect method of intes-
tinal infection is necessary in order to explain the severe cases of
uncinariasis observed. The average boy or girl suffering from this
disease is not conspicuous because of personal cleanliness. Bath tubs
are not found in their homes, and from physical examinations I made
I can testify that not only their hands and finger nails, but their entire
bodies also, are far from a condition unfavorable to parasitism. Suck-
ing the fingers, picking the teeth, biting the finger nails, or even eat-
ing a piece of bread with soiled hands will usually suffice to convey
some dirt between the lips. The sand on which the children play
must be heavily infested with hookworm larvae, and it certainly can
not be an exceptional occurrence that the children unconsciously carry
microscopic worms to their mouth. Further, the chances for infec-
tion of surface wells, from which the drinking water is taken, are very
great in any sandy soil. If, however, cutaneous infection were the
rule, I should expect to find all barefooted children in the infested
area suffering not only from ground itch the entire summer, but also
from severe infections of hookworm disease.
Hair. The hair on the head appears to be about normal, but in cases
contracted before puberty, the beard and the hair on the body (pubis,
armpits, arms, legs) are usually undeveloped. I have seen patients
20 years of age upon whose body hairs were almost absolutely lacking.
Breasts. The breasts of females, who have contracted hookworm
disease before puberty, remain more or less undeveloped. In a girl
of 20 years of age, for instance, the breasts may not be developed
beyond those of a girl of 8 or 9 years old.
Nails. The color of the tissue directly under the nails varies with
the anemia.
HEAD.
Face. The face has an anxious, stupid expression, and in severe
cases is more or less "bloated" (edematous).
In fact, a prominent symptom of uncinariasis in practically all
animals in which it occurs is the development, in severe cases, of a
more or less extreme edema. To use the rural vernacular, "the face
bloats," and "the feet and ankles swell." The symptom in question
is more or less irregular in man as it is in other animals, notably in
sheep, appearing and disappearing at intervals. Upon several occa-
65
sions I was informed that this symptom interfered seriously with the
school attendance, for if the children sat still a long time in school
"they began to swell." Quite generally, as was to be expected,
testimony was to the effect that the edema was less frequent in the
winter than in the summer.
Eyelids; conjunctivas. An examination of the eyelids exhibits the
visibility of the blood vessels in light cases, but an absolute marble
whiteness in very severe cases, with all possible intermediate stages
corresponding to the general degree of anemia.
Eyes. While looking at the eyelids for anemia, the observer fre-
quently notices that the pupils are dilated or that they dilate readily
and that the eyes are dull, dry, and usually of a chalky white. If the
patient is directed to stare intently into the observer's eyes, there will
be noticed a symptom which it is difficult to describe, but which I have
found more constant than almost any other noticed, namely: After a
moment, the length of time apparently varying slightly according to the
degree of the disease, the pupils dilate and the patient's eyes assume a
dull, blank, almost stupid, fish-like or cadaveric stare, very similar to
that noticed in cases of extreme alcoholic intoxication. I am not familiar
enough with the stare of anemic patients in general to state how
common this peculiar look is among them, nor have 1 found any of my
medical friends who could give me much information on this subject;
but I can state that among the several scores of anemic people whom I
examined on this trip, in the severe cases with two exceptions, I found
the eggs of Uncinaria americana in every one (whose feces were ex-
amined) in whom I observed that indescribable stare; the two excep-
tions in question were city boys, both of them sons of a confirmed
inebriate; further I failed to find the eggs present in certain extremely
anemic patients in whom the stare was not noticed. It certainly was
absolutely absent from a number of typical cases of malaria. Toward
the end of the trip, I found myself unconsciously relying more upon
the presence or absence of the blank stare than upon any other single
symptom, except of course the presence of the eggs in the stools.
I will not go to the extent of stating that this stare is diagnostic for
uncinariasis (and I will even warn that in dark eyes it is less evident
than in eyes of light color), for 1 do not feel that I have had experi-
ence enough with the peculiarities of eyes in various diseases to speak
authoritatively upon the subject. I simply mention this pecul-
iarity in connection with the discussion of the eye as a symptom
which, as my investigations progressed, made more and more of an
impression upon me. Upon calling the attention of several local physi-
cians to this peculiar stare, they informed me that it was a totally new
symptom to them, but that after examining several cases they found
it a very prominent symptom. As a general rule the eyes in advanced
stages are dry. In this connection it may be noticed that several
19558 No. 1003 5
66
authors have mentioned the glassy appearance of the eyes of dirt-
eaters.
Since my return, several of my clinical friends with whom I have
discussed this symptom have expressed some skepticism in regard
to the matter. Although thoroughly convinced of its existence, for
I saw it too frequently to be deceived, I have written to several
Southern clinicians requesting them to give me the benefit of their
independent observations on this point. Up to the time of reading
" galley proof" of this report the following replies have been received:
[Extract from a letter from Dr. Hilsman, January 2, 1903.]
' ' Replying to your letter, 24th ultimo, I have to say that I have examined the
patients that we saw in the country, and on making them gaze intently at me as you
directed, I observed the vacant stare that you described, but did not observe the
dilation of the pupils. The stare is very much like that of an epileptic as he begins
to recover from a fit.
"These cases have improved under treatment suggested by you. The little girl
passed a large number of the worms."
[Extract from a letter from Dr. M. A. Clark, January 30,1903.]
"I have delayed, hoping to find the eye symptom you mention, but I have not yet
found it. My cases are improving slowly."
Dr. James Edward Stubbert, of New York, who spent some years
in Central America and has seen many cases of hookworm disease, has
stated to me that he has frequently observed the peculiar stare in the
eyes of dirt-eaters.
In this connection it is also not uninteresting to note that some
"worm doctors" claim to lay special stress upon the eye in making
their diagnoses; also that dilation of the pupil, due to irritation by
intestinal worms as well as to anemic conditions, is recognized by
certain prominent writers on the eye; further, that dilation of the
pupil is also a symptom upon which many children's nurses depend
in suspecting the presence of worms.
Sandwith (1894, p. 12) states that the eyes of his patients showed a
pearly white conjunctiva, singularly in contrast with the yellow color
of the face. Dr. Scott examined several men for him with the
ophthalmoscope, and found in half of them a normal f undus, and in the
other half a very pallid fundus. The refraction tests showed astig-
matism in many cases.
Nostrils. The visible mucous membrane of the nostrils becomes
pale in proportion to the anemia.
Lips and gums. The lips also become pale in proportion to the
anemia, the inner surface of the lips and the outer surface of the gums
frequently presenting almost a chalky white appearance.
Teeth. Irregularity of the teeth was so common among patients
affected with uncinariasis that the question arose in my mind whether
this was not to some extent an expression of the general underdevel-
67
opment of the body due to this disease. The point at issue calls for
the opinion of a dentist rather than that of a zoologist. The decayed
teeth of dirt eaters have been recorded in early writings on this habit.
Tongue. In some cases the tongue was coated. A number of
observers have already called attention to this symptom, which was
by no means general in the cases I observed.
Several authors have remarked upon the presence of black, brown,
or purple spots on the tongue in cases of uncinariasis, and the view
has been advanced that these present a valuable aid in diagnosis, and
in some cases, at least, that they disappear on treatment. In the
cases which came under my observation, I looked very carefully for
this symptom. In many instances I found more or less distinct
purplish to brownish spots, irregularly round or elongate in shape,
and these may or may not be identical with the spots described by the
authors cited. It was, however, noticeable that in many cases where
these spots were observed, the patients were accustomed either to
chewing tobacco or to dipping snuff. In fact, some of the spots in
question I am inclined to refer to the use of tobacco or snuff.
Whether all cases are to be explained in this way is, however, open
to question, with probabilities against such explanation. Neverthe-
less, it is well for practitioners to be forewarned upon this chance
of error in diagnosis. Several authors have assumed that the spots
on the tongue represent a symptom which has only recently been
observed in this disease. In this connection, it is interesting to note
that early authors for instance, Cragin (1836a) and Imray (1843) in
writing upon dirt-eating have described these same spots.
NECK.
The cervical pulsations are often very evident, and in some cases
may be seen from 6 to 12 feet away. (See Circulatory system, p. 72.)
THORAX.
In emaciation the thorax corresponds to the general emaciation of
the extremities. In some cases the ribs are very prominent..
Heart. See page 72.
Breasts. See page 64.
ABDOMEN.
"Pot-belly " or " buttermilk-belly" dropsy, and tympanites. The con-
dition known as "pot-belly" or "buttermilk-belly" is exceedingly
common in uncinariasis, especially in extreme cases in summer. It is
a distension of the abdomen, due apparently to two factors: (1) a
gaseous distension of the bowels, and (2) the presence of an excess of
fluid in the abdominal cavity.
I hasten to add that I have not seen a single autopsy in man infected
with uncinariasis, but the same abdominal distention is found ir
68
animals suffering from this disease, and a number of post-mortem
examinations, especially on sheep, have given the conditions described.
Lutz mentions flatulence of the lower abdomen as a common symp-
tom, and Sandwith (1894, p. 11) found it present to a slight extent in
one-third of the cases.
Hair. See page 64.
GenitaUa.SQQ page 78.
EXTREMITIES.
Nothing of any particular note was observed in connection with the
bones; for the muscles see p. 73. In many cases the feet and ankles
were swollen, and in several cases the legs were marked with ulcers.
See p. 59.
According to Sandwith (1894, p. 12), edema of the legs, like albu-
minuria, is to be seen only in the worst cases, and some of these had
general edema when admitted in a dying condition.
GENITALIA.
See page 78.
MUCOUS MEMBRANES.
All mucous membranes correspond, in respect to their color, to the
grade of anemia. (See Eyelids, p. 65; nostrils, p. 66; lips and gums,
p. 66; tongue, p. 67; genitalia, p. 78.)
EXCRETIONS AND SECRETIONS.
I have no observations to record in regard to the urine. Sandwith
(1894, p. 11) states that
"The urine is not unlike that of ordinary anemia, neutral or alkaline in equal
proportion, and rarely acid, pale colored, with specific gravity ranging from 101C
to 1015. A trace of albumen was present in all the most advanced cases, without
casts under the microscope."
According to Zinn and Jacoby (1898, p. 16), Lussana (1890) found
in the urine of patients suffering from uncinariasis a poisonous sub-
stance of the nature of a ptomaine, which caused extensive changes
in the rabbit's blood, especially a change in the number of red blood
corpuscles, and also poikilocytosis. These results are said to have
been confirmed by Arslan (1892).
FECES.
Consistency. The feces may be hard or soft, according to the pres-
ence of constipation or diarrhea.
Reaction. In reaction the feces may be acid, alkaline, or neutral.
Color. In a large proportion of medium and severe cases, the feces
are reddish to brown in color. In some cases blood is present.
69
Blotting paper test. In about 8 out of 10 medium and severe cases,
if a portion of the feces is placed upon white blotting paper, and
allowed to remain there for twenty minutes to several hours, it leaves
on the paper a reddish brown stain similar to a blood stain. This
test will be found useful by physicians who are not prepared for
microscopic tests.
Microscopic examination. If feces less than twenty-four hours old
are examined microscopically, the eggs will be found in various stages
of segmentation. If feces over twenty-four hours old are examined
the free embryos also are usually found. If free embryos are found in
perfectly fresh feces, the diagnosis of infection with the worm (Stron-
gyloides stercoralis a ) of Cochin-China diarrhea must be made, and this
parasite we may find in the same patient in whom uncinariasis is
present.
CIRCULATORY SYSTEM.
The symptoms of the circulatory system are the most marked and
most common; they seem to develop after the symptoms of the diges-
tive system, but before those of the nervous system.
ANEMIA.
In all medium and severe cases, the anemia is what first attracts
attention. This varies in intensity not only in proportion to the degree
of infection, but also to a considerable extent in proportion to the
length of the period of infection. For instance, 100 worms may be
expected to produce a greater anemia within a given time, say one
year, than will 50 parasites. But 50 worms may be expected to pro-
duce more anemia in two years than in one.
In some medium cases, the blood vessels of the conjunctive may be
more or less visible, and the visible mucous membranes of the nose,
mouth, and vulva, may be more or less of a normal or subnormal
color. In the extreme cases, these structures may be as white as
marble or paper. In the same way the color of the skin will vary
(see Skin, p. 59; Nails, p. 64) from an almost natural hue to a whitish,
lemon yellow, or tan color.
This worm is probably much more common in this country than supposed. The
cases known to me to date are: Baltimore, Md. 1 case, 1 death; reported by Strong,
1901. Richmond, Va. 1 case, death; reported by Thayer, 1901. Anne Arundel
County, Md. 1 case, death; reported by Thayer, 1901. Washington, D. C. 4
cases, death; unpublished, Zool. Lab., U. S. Public Health and Marine-Hospital
Service. Ohio 1 case, death; unpublished, Dr. A. P. Ohlmacher (mentioned
here by kind permission of the observer). San Francisco, Cal. 3 cases, ? deaths;
unpublished, Dr. P. K. Brown (mentioned here by kind permission of the observer).
Cuba ? cases, ? deaths; unpublished, Dr. John Guiteras (mentioned here by kind
permission of the observer). Porto Rico ? cases; ? deaths; unpublished, Dr. P. K.
Brown.
70
Blood. I did not stop fo** blood counts, as these have been made
by other men, and while they are exceedingly interesting from a path-
ological standpoint they have not appealed to me as so direct a method
of diagnosing intestinal parasites as is the fecal examination. In gen-
eral it may be said that the blood of man corresponds to the blood of
sheep, goats, cattle, dogs, etc., suffering from the same disease; in
other words, the severer and longer the infection, the thinner the
blood. In the vernacular of the sandlapper, it is u like water." It
may here be added that in early literature on dirt-eating, several
authors remark upon the water-like appearance of the blood.
Speaking in more technical language, the blood has been shown by
Ashford to possess the following characteristics:
"(1) A severe anemia, falling as low as that of Addison's anemia in count of red
cells in some cases. (2) A very low hemoglobin average and a very low color index.
(3) A marked eosinophilia in some cases; 40 per cent reached in one case. This
follows the observation of Neusser. (4) No leucocytes common to the disease itself.
Leucocytosis recorded is always apparently due to complications, as rioted. (5) Fre-
quent presence of normoblasts, and in some cases megaloblasts, but never a majority
of megatoblasts. (6) Poikilocytosis common. Manson denies this."
Ashford gives the following interesting table of blood counts:
71
%l | s s I" % Is "SSS^
Z ,CH
If
&
a*
||
1| .
.22
l-slH|ffl>.| B |.g iggjlg |S <h)3g
I - lf*ffi II ilStl
itlti|iE rf !
"333 !s'3^ 5*3
iS5i*sgs*iii^ta|iIlil|l
||l|fi|a.|||I|.^||2.2ls.g.g "iitilS'i
ill HglS if
3--PS37H'3o3^i3 : ^Q33 t - i 3 oS o3S :) m (33 2^ 32353d K9
3 ri S ^2 oZ 'vi^H i^^JftjCIaSx^H^^Hplrrt^^^SS^-^ !3 53 53 w IH 0,^3 -^<
oiqno aad
w <o
00000000
oiqno J9d
oujsoa jo
jo
jo
CO 0500000!
oo to co co ic to o
iC O> -^ Tfi -^ iC O
to 10 to to to to to
;ggg gog
t> (N-^tO GOlC T}<l> rH ^ I> <
8 8 8 S S
snao P3H
> to x) o co ^f o ^ 'C' V(
^, ^, ~ '. c ^ 3 ^ -S;
5t> OO
O i-H CM CO ^ iO to I> COO5I
2 5 ^
a a a
i.8
~
'$
'
o o
o
a aaa
72
Cervical pulsations. In the rural vernacular, "jerking at the neck"
or " jumping at the neck" refers to an anemic symptom which is
exceedingly prominent in most medium cases and in all extreme cases
of uncinariasis. It is simply the violent pulsations of the cervical
vessels, visible sometimes at a distance of 2 to 4 meters.
Heart. Nearly all medium and severe cases complain of having
"heart disease" or a "fluttering of the heart," and many of the
patients are taking medicine for this symptom. (See also p. 35.) We
have here, of course, the usual cardiac symptoms of an extreme anemia.
"Palpitation over the heart, in the epigastrium, and in the temporal arteries is sure
to be present in bad cases, while the anemic murmurs of heart and neck are solely
dependent upon the degree of anemia, and can be banished by a prolonged course of
iron. Hypertrophy of heart was noted and verified after death in some of the
advanced cases. ' ' (Sandwith, 1 894, p. 12. )
Pulse. Pulse varies from 80 to 132 per minute. In medium and
severe cases I noticed about 120 per minute probably more frequently
than either a higher or a lower pulse. This was found in young and
middle-aged (probably more commonly in children), in males and
females, and yet without a temperature which was distinguishable by
the hand as especially high.
TEMPERATURE.
Not being able to follow any cases for any length of time, hence not
being able to make continued observations on the temperature, I con-
sidered that observations in other lines were more important under the
circumstances. Hence I did not take temperatures carefully. Accord-
ing to observations by various clinicians, there may be subnormal or
normal temperature, or the thermometer may register 100 to 102 F.
"The skin is always cold, and the temperature before thymol generally subnormal
in uncomplicated cases. After excluding any fever produced by concurrent diseases
and any defervescence caused by thymol, I find that one-third of my patients had a
normal temperature during their stay in the hospital, but that two-thirds had a dis-
tinctly subnormal range, varying from an average of 36.3 C. a. m. to 36.9 C. p. m.
"Many of these patients when convalescent had an increase of half a degree,
night and morning.
"Surgeon-Major Giles suspected that many of his patients in Assam had suffered
from fever at the onset of their malady, and he was confirmed in this impression by
observing pyrexia in the monkeys he fed on anchylostoma embryos. After elimi-
nating all those who had fever in the hospital, or a history of intermittent fever or
any enlargement of the spleen, I found that 68 per cent of the remaining stated that
their trouble had begun with a few days' fever." (Sandwith, 1894, p. 12.)
RESPIRATORY SYSTEM.
NOSTRILS.
See page 66.
RESPIRATION.
Many patients complain of a difficulty in breathing, especially after
exertion. This symptom is quite natural, in view of the low condi-
73
tion of the blood and the emaciation of the muscles. Respiration is
rather variable and does not appear to be a symptom of very great
value; it may be slow, or it may be increased to about 30 or more per
minute. According to Sandwith (1894, p. 12) dyspnea and noises in
the ears were present, as might be expected with marked anemia.
MUSCULAR SYSTEM.
EMACIATION.
A progressive emaciation is more or less common, especially in
severe cases. The arms and legs seem to be reduced to skin and
bones; the chest is so emaciated that the ribs are very prominent and
the beating of the heart is very evident. What little muscle is left
is soft and flabby.
Emaciation is, however, not present in all cases, and even in some
medium infections the muscles may be well formed and more or less
hard. I recall one case in particular: A boy about 14 who showed a
heavy infection microscopically, a clear clinical history of uncinariasis
of several years standing, decided anemia, distinct cervical pulsations,
abdomen rather distended ("pot-bellied"), yet his arms and legs were
well formed and his muscles surprisingly solid for a patient in his con-
dition.
Sandwith (1894, p. 13) found the average weight of 100 grown men
upon admission to the hospital to be 117.5 pounds; the average height
of these men was 5 feet 5.5 inches, which by Dawson's tables should
scale at least 135 points. Of the patients who stayed in the hospital
more than two weeks 70 per cent gained weight, 22 per cent lost, and
8 per cent remained stationary. The average loss of weight was 3.2
pounds, and was, of course caused by the necessary starvation, thymol,
and purging. The average gain was 5.4 pounds, some patients gain-
ing as much as 15, 17, 18, or 20 pounds.
GREAT PHYSICAL WEAKNESS.
One of the most pronounced symptoms complained of is a general
weakness. The patient states that he is obliged to rest after exer-
tion. In light cases a feeling of lassitude is experienced without
being able to assign it to any particular cause; as a result, it is gener-
ally assigned by other people to laziness. In medium cases the patient
may be able to work one to three or four hours before becoming
exhausted; in very severe cases he will scarcely be able to walk across
the room, or he may be confined to the bed for weeks at a time.
A physical examination usually shows an emaciation proportionate to
the weakness.
74
DIGESTIVE SYSTEM.
LIPS, GUMS, TEETH, AND TONGUE.
See p. 66.
NAUSEA.
Nausea was not noticed. % Sandwith (1894, p. 11) states that vomiting
and nausea are rarely complained of.
APPETITE.
The appetite may be light or ravenous. According to Sandwith,
the appetite is invariably affected, sometimes ravenous at beginning,
but later always capricious and diminished. The English nurses
report to him that the patients were always begging for medical com-
forts or cigarettes, even in the middle of the night, when other
patients were asleep. Among 40 men caref ully examined. 16 said that
their appetite was once greatly exaggerated, 16 pleaded diminution
from the beginning of their illness, and 8 believed that their appetite
was normal until the anemia became very marked.
Perverted appetite, "Dirt-eating" The most important point to be
noticed in connection with the appetite is the abnormal desire for some
particular article of food. Frequently this is a preference for some-
thing sour or bitter.
Man}' patients with uncinariasis are known throughout the village
or county as being especially fond of pickles. 1 have seen boys and
girls in advanced cases of this disease who would greedily devour an
entire bottle of pickles. Some patients are especially fond of sucking
lemons, or lemons and salt, or salt alone. Others are known for their
desire to chew coffee, or to drink large quantities of strong coffee
without milk or sugar. Some are abnormally fond of buttermilk.
Others are noted as "resin-chewers." Some are accused of " lapping
sand." Many are accused of eating clay or dirt.
Dirt-eating has been discussed by a number of authors, opinion
being divided as to its status. Some writers look upon it as the cause
of the disease; others view in the habit only a symptom or a result;
still others consider it nature's treatment of a diseased condition.
Among helminthologists there seems to be the impression that dirt-
eating is especially likely to lead to infection with parasites. Among
Southern physicians I found the idea quite prevalent that dirt-eating
was one of the causes of the condition which I have classed as extreme
uncinariasis.
During the trip now under discussion, I have had opportunity to
observe many so-called dirt-eaters. As most authors state, it is
exceptional that one will acknowledge that he eats dirt. 1 believe the
explanation of this denial is very clear, namely, not only is there a
certain amount of disgrace connected with the reputation of being
a dirt-eater, but probably not over one person in ten, or possibly
75
in twenty, accused of eating dirt ever does so. The other nine to
nineteen have their abnormal appetites developed in a different
direction, namely, pickle-eating, lemon-sucking, coffee-chewing, resin-
chewing, etc.
Among the articles eaten by these "dirt-eaters," various authors
mention charcoal, chalk, dried mortar, mud, clay, sand, gravel, stones,
shells, rotten wood, cloth, garments, paper, tobacco pipes, mice,
young rats, etc.
It is, I believe, an error to attempt to reduce this abnormal habit to
any one common basis. In general, however, it may be stated that
the alleged "dirt-eating" in this country practically represents the
severe cases of uncinariasis. To attempt to reduce dirt-eating to
infection with worms, particularly with Uncinaria americana, will
doubtless be thought extreme, more particularly by Northern physi-
cians. Still the idea is not a new one, and a moment's consideration
will show that this view is far less extreme than it at first appears.
For an excellent general discussion of dirt-eating, with extensive
references to literature, the reader is referred to Le Conte (1845).
For the purpose of the present paper it will suffice to call attention to
certain facts and analogies. The habit of eating slate pencils, paper,
and other objects by chlorotic girls is more or less commonly known.
Pregnant women, also, may develop an abnormal appetite, which
takes different phases, including dirt-eating. It is recorded that the
Javanese women eat certain dirt in order to improve their appearance.
In certain localities in tropical America (Orinoco) the natives eat earth
during the overflow of the river when they can not obtain their regu-
lar food. Earth eating is said to be common and not injurious in cer-
tain parts of Africa. According to Sandwith (1894, p. 9), on the day
of the maximum high Nile, and the general rejoicings thereupon, the
town crier, who is on the lookout for backsheesh, presents "teen
ibliz" (Nile mud) with a lemon to the inhabitants for luck, and many
of them eat of it. Dogs, horses, cattle, hogs, and alligators are
recorded as eating clay and sticks. The Alaskan seals, when infected
with round worms, eat pebbles. Elephants, when infected with
flukes, eat a certain kind of clay until a looseness of the bowels is
produced. I have frequently heard Texas grangers attribute the
death of cattle to eating sand, and in post-mortem examinations of
cattle, sheep, and goats, in an anemic condition from intestinal worms
(verminous gastritis caused by Hsemonchus contwrtus, H. Ostertagi,
etc., and infection of small intestine with Uncinaria trigonocephala and
U. radiata), I have repeatedly noticed in the stomach and intestine
large quantities of sand; so that the farmers present declared that this
was the cause of death. Dogs infected with intestinal worms eat
grass. Cats also frequently eat grass, probably from the same cause.
Children infected with eel worms (Ascaris lumbricoides) are known to
76
occasionally eat dirt, and I know of one such case where the habit
ceased when the worms were expelled.
In view of the comparisons cited, it would seem that the idea of
considering dirt-eating as a manner of infection with parasitic worms,
although conceivable for some cases, is hardly correct as applied to
most instances. That dirt-eating is an abnormal appetite due to a
diseased condition (anemia and a disordered digestive system) as sug-
gested by several authors as early as the first half of last century,
seems to me to be an explanation of much more general application;
and that this anemia and enteritis or gastritis may be produced by
parasitic worms is an established fact. In this connection, it is inter-
esting to note that Hancock (1831, p. 67), in discussing dirt-eating,
mentions "worms preventing the nourishing effects of food;" Imray
(1843, p. 310) remarks that "worms in considerable numbers were not
uncommonly accumulated in the intestinal canal." Further, it is sig-
nificant that various authors, in discussing the treatment of dirt-eating,
attribute more or less success to certain drugs which are in fact used
more or less in treating for intestinal parasites. Thus, Cotting (1836a)
refers, as stated above, to the decrease of dropsy and of dirt-eating
corresponding to the more general use of calomel; sulphate of iron is
mentioned by Cragin (1836a), Pollard (1852), and others; according to
Pollard (1852), copperas is a popular and successful remedy among
the negroes; Hancock (1831) refers to a remedy containing arsenic
as having had great success; Jordan (1832) states that dirt-eating
decreased upon destroying the huts and moving the families to some
other location.
To summarize: While it would seem decidedly extreme and unwar-
ranted to maintain that dirt-eating is necessarily an indication of
infection with intestinal worms, still I believe the conclusion is justi-
fied that it is undoubtedly a more or less common tendency in such
infections, not only in man but also in other animals. It may be
classed with the chewing of slate pencils, resin, coffee, sucking of
lemons and salt, etc. , as an abnormal appetite due to the anemia and
abnormal condition of the intestinal tract. Further, for all practical
purposes it is not much of an exaggeration to look upon most, if not
all, so-called dirt-eaters of the sand areas of our Southern States as
representing severe cases of uncinariasis.
Sandwith (1894) states that 26 per cent of his patients confessed to
eating earth, and he refers to "earth hunger" as sometimes the cause
and sometimes the effect of hookworm disease.
PAIN IN THE STOMACH; INDIGESTION.
Many patients complain of colicky pains "in the stomach," and
will indicate the region between the navel and the ensiforni cartilage
as the seat of the "misery." Indigestion is frequently mentioned,
and the tongue is occasionally coated.
77
Just how much the indigestion is due to uncinariasis and how much
to other causes may be considered an open question. Foul breath is
mentioned by some authors as a common symptom of uncinariasis, but
this has not been particularly noticeable in many of the cases I saw.
Many authors explain the tendency to dirt-eating as an effort to neu-
tralize the hyperacidity of the stomach. As 1 have just shown (p. 74),
however, many patients with uncinariasis eat pickles and suck lemons.
According to Sand with, a gnawing, throbbing pain in the epigas-
trium is the first symptom complained of, chiefly because it is constant,
whereas a severe colic and borborygmi (rumbling of bowels caused by
gas) of intestine are present from time to time. 1 was unable to con-
firm the constancy of the pain.
CONSTIPATION AND DIARRHEA.
Sandwith (1894, p. 11) states that when the patient is not under
thymol and purgative treatment, constipation is a very constant symp-
tom in hospital cases; 60 per cent had suffered for a long time from
obstinate constipation, 28 per cent had had diarrhea before admission,
and 12 per cent had no recollection of being troubled with either.
" None of the figures depending upon the memory of the patients
must be taken as absolute truth, as the intelligence of many is of a
very low order." Diarrhea, and even dysentery, are not uncommon
in very advanced cases, especially those complicated with Bilharzia
( Schistosoma, which has not been reported as endemic in the United
States), or ulceration in the rectum; and unless the patient is robust
enough to support thymol, such cases are apt to end fatally.
In my own cases I found both constipation and diarrhea, but I am
not in a position to state that either symptom was regular or charac-
teristic for any given degree or stage of infection. In severe cases
diarrhea was certainly more or less common.
Feces. See page 68.
NERVOUS SYSTEM.
The nervous s}^mptoms usually develop later than either the intes-
tinal or the circulatory symptoms.
EYES.
See page 65.
EARS.
According to Sandwith (1894, p. 12), noises in the ear are present.
None of my patients complained of this symptom.
MENTAL LASSITUDE, HEADACHE, DIZZINESS, AND NERVOUSNESS.
Not only does physical exertion result in exhaustion, but mental
exertion has to be avoided. The children complain that they are
unable to study and that any continued application to books results in
78
severe headache. This feature of the disease is fully confirmed by
the testimony of both teachers and parents, who assert that children
of this class are usually much more backward (and even stupid in
their studies) than other children not showing the symptoms under
discussion.
Dizziness is very commonly mentioned by the patients. This feel-
ing, which they usually speak of as a "swimming in the head," is
experienced especially upon rising suddenly from a chair or a bed.
Nervousness does not seem to be so commonly complained of as
mental lassitude, headache, and dizziness. Still it is more or less fre-
quently mentioned, more particularly by the girls and women.
Among girls from about 13 to 20 years of age it was quite notice-
able that they were more timid and more emotional than were their
healthier sisters.
According to Sandwith (1894, pp. 11-12), there is pain in the head,
generally referred to the temples, while in the knees there is almost
invariably present great weakness and some pain; occasionally there
is in addition pain in the shoulders. Giddiness is another very gen-
eral symptom, and it is this as much as anything else which compels
the patients to give up work. The worst cases are those which are
nearly always asleep, and can not be interested in anything when they
are awake. On the whole, sleepiness is decidedly a symptom. Dense
stupidity, associated sometimes with reiterated demands for a favor
already granted, shows that the bloodless brain is affected in all
advanced cases, and at least three times Sandwith (1894, p. 13) found
a condition of weak-mindedness which would have warranted the
patients being sent to the asylum.
PATELLAE REFLEX.
Absence of patellar reflex is reported in cases of general debility
and muscular weakness. Sandwith (1894, p. 13) found this reflex
unaltered in 35 per cent of the cases examined, completely absent in
48 per cent, decidedly diminished in 5 per cent, and a little exagger-
ated in 12 per cent, all of which were early cases.
GENITAL SYSTEM.
EXTERNAL GENTTALIA; SEXUAL FUNCTION; MENSTRUATION; STERILITY.
In cases where infection has taken place in early childhood, the
delayed development of the genital S3 T stem is very marked. Patients
of 16 to 22 years of age may not be better developed than healthy per-
sons of 11 to 15 years. Menstruation may be very irregular, espe-
cially in summer. This same condition is insisted upon in many early
writings on dirt-eating. Mothers frequently ascribe the condition of
their daughters to the absence or irregularity of the menstruation as
is mentioned also in early writings on dirt-eating.
79
Sandwith (1894, p. 13) found impotence to be a decided symptom in
hookworm disease. Of 38 men especially examined on this point, 24
had completely and 5 had almost entirety lost their virile power,
while of the remaining 9 men, 5 aged from 19 to 25 had their puberty
considerably delayed.
TENDENCY TO ABORTION.
Among women affected with uncinariasis I found a marked tend-
ency to abortion. Given a woman about 28 years old who had been
married nine years a not uncommon history is that she has had 3 to
5 children and 3 to 4 miscarriages, and she looks to be about 50 }^ears
old. Not being able to follow these cases through their entire
medical history and the history of their husbands, I must leave the
question open as to how many of these abortions are to be attributed
to uncinariasis and how many are due to other causes. In the country
districts I was thrown in with the anemic not with the healthy
families, hence 1 have no good basis for comparison of these two
classes for the particular localities visited. In some cases a history
of venereal disease was suspected or admitted; in others, the abortion
came on after pitching fodder; in some cases the patients had taken
more or less quinine during their life, under the supposition that they
had malaria; and in still other cases, my suspicions were aroused in
other directions. The determination of the exact relation of uncina-
riasis to the miscarriages, which are certainly strikingly prevalent,
must be left to those who can follow the cases for a longer period of
time.
PREVALENCE OF UNCINARIASIS IN THE UNITED STATES.
In several earlier papers (1901, p. 524; 1902 a, p. 778; 1902 b, pp. 183,
212) I have advanced the view that uncinariasis must be more common
in this country than is generally supposed. In my preliminary report
on this trip (see above, p. 35), I said that: "There is in fact not the
slightest room for doubt that uncinariasis is one of the most impor-
tant and most common diseases of this part [South Carolina] of the
South, especially on farms and plantations in sandy districts."
Harris (see above, p. 36) went even farther than this and claimed
that uncinariasis is "the most common of the severe diseases of the
South."
In considering the subject of the frequency and economic impor-
tance of the disease under discussion, I do not wish to seem to under-
estimate the prevalence of tuberculosis and of venereal diseases among
the negroes or of malaria among the whites. Further, I recognize
the fact that at the present moment an exact mathematical estimate
can not be made. Speaking in general terms, however, the facts at my
disposal at present seem to indicate that taking the Southern Atlantic
80
States as a whole, uncinariasis must be considered as one of the most
common and widespread maladies; in frequency it belongs in the
general class with malaria, tuberculosis, and gonorrhea.
In cities and in rural clay districts it is probably less common than
any one of these three maladies, for such localities may present local
foci of infection for the diseases in question, while the local foci of
infection with uncinariasis are much more limited.
Among the negroes of the rural sand districts, uncinariasis seems to
be much less common than either tuberculosis or gonorrhea. Its
apparent rarity may, however, be deceptive (see p. 51).
Among the whites of the rural sand districts, uncinariasis is appar-
ently the most common disease found. Nevertheless, in some sand
districts, probably with a clay or other impervious subsoil favorable
to the formation of marshes, malaria rivals uncinariasis for first place.
From these qualified statements it will be seen that I do not feel
justified in adopting the view advanced by Harris, namely, that uncin-
ariasis is a the most common of the severe diseases of the South."
In all probability, further study will show that in Mexico, Central
America, and parts of South America, hookworm disease is more
important and more common than in the United States.
Sandwith (1894, pp. 5-6), in discussing the frequency of this disease
in Egypt, says :
"It is impossible to know what amount of the population [of Egypt] is affected,
but the statistics of the recruiting commissioners for 1892 are worth quoting. Nearly
every adult male peasant is liable for conscription, and the conscripts are immedi-
ately examined in their villages. In upper Egypt 5,988 men were called, and 200,
or 3.3 per cent, were rejected for anaemia. In lower Egypt 661, or 6.2 per cent were
rejected from this cause out of 7,420 men. Every province furnished anaemic rejec-
tions, but Menoufieh came highest on the list with 13.9 per cent, while I find from
hospital statistics that no less than 15 villages in that province are infected. The
recruiting medical officer, who is an Englishman, only rejects those who are obvi-
ously too anaemic to serve with the colors, accepting many who are already the
hosts of the bloodsucking worm. Thus the medical reports for the Egyptian army
show that in 1890 there were 114 admissions to the hospital for anaemia, in 1891, 107
admissions, and in 1892, 170 admissions. In 1891, 22 soldiers were invalided from the
service for anaemia, and 65 in 1892, besides 1 death. The number of admissions for
debility is equal to those for ansemia, and doubtless includes many cases of anchy-
lostomiasis."
Dobson (1893, p. 63), examined 547 of the healthiest looking coolies
from India and found hookworms in no less than 454 of them.
CLINICAL DIAGNOSIS OF HOOKWORM DISEASE.
As stated above, a man who is familiar with this disease should
have no difficulty in recognizing severe cases, especially if he is in the
area of infection. In light and medium cases, however, it is unsafe to
make a diagnosis upon symptoms alone, unless such cases are associated
81
in the same family or neighborhood with severe cases. The best and
most reliable method of diagnosis is by fecal examination, although in
blood examination increased eosinophilia indicates the possibility of
intestinal parasites.
First of all let us recall that uncinariasis is a possibility which should
be considered in connection with all cases of anemia, especially among
earthworkers, as in miners, brickmakers, canal diggers, farmers, etc.,
or in persons returning from the tropics, and among persons who have
a history of residence on sandy soil. Three methods of fecal examina-
tion are open to us the blotting-paper test and the microscopic and
the gross examinations.
BLOTTING PAPER TEST WITH FECES.
For persons who are not in a position to make a microscopic exami-
nation, the blotting-paper test (referred to on p. 69), will be found
very useful. To make the test, use only fresh feces. Place an ounce
or more of the stool on a piece of white blotting paper (any absorbent
white paper will answer the purpose); allow it to stand for twenty to
sixty minutes; remove the feces and examine the color of the stain.
In about four out of five cases of medium or severe uncinariasis, the
stain is reddish brown and immediately reminds one of a blood stain.
In making this test on anemic patients, piles should of course be
excluded.
It developed in my work in the Virginia penitentiary, that this test
is open to error in dealing with criminals. In order to avoid work,
convicts, especially hard-labor contract convicts, occasionally produce
a hemorrhage purposely by wounding the mucosa of the rectum by
means of some sharp instrument.
19558 No. 1003 6
82
7-1
FIG. 43. Egg of the common ascaris (Ascaris lumbricoides) of man, as found in feces. Seen with
superficial focus. Greatly enlarged. (After Stiles, 1902b, p. 202, fig. 158.)
FIG. 44. The same, as seen with median focus. Greatly enlarged. (After Stiles, 1902b, p. 202, fig. 159.)
FIGS. 45-54. Embryology of the common ascaris (Ascaris lumbricoidca) of man, showing the changes
undergone by the egg after being discharged in the feces. (After Leuckart, 1867, p. 213, fig. 154.)
FIG. 55. Embryo of the common ascaris (Ascaris lumbricoides) of man, in the eggshell. (After
Leuckart, 1867, p. 215, fig. 156.)
FIG. 56. Free embryo of the common ascaris (Ascaris lumbricoides) of man, casting its skin. (After
Leuckart, 1867, p. 214, fig. 155.)
FIGS. 57-64. Embryology of the common pinworm (Ori/uris rermicularis) of man, showing the changes
undergone by the egg while in the female worm. (After Leuckart, 1868, p. 322, fig. 191. )
FIG. 65. Embryo of the common pinworm (O-Jcyuris vermicularis) of man, in the eggshell, as found in
fresh feces. (After Leuckart, 1868, p. 328, fig.' 196.)
FIG. 66. Full-grown embryo of the common pinworm (O.i-i/tirix rermicularis) of man, after it has
escaped from the eggshell. (After Leuckart, 1868, p. 328, fig. 195.)
FIGS. 67-70. Egg of the common whipworm ( THchuris tricliiura) of man, showing changes undergone
while still in the female worm; fig. 70 is the stage found in fresh feces. (After Leuckart, 1868,
p. 491, fig. 275.)
FIGS. 71-73. Later stages of development of an allied whipworm (Tri<-fni.rix [tin is) of sheep and
FIG
cattle, showing changes after the egg escapes in the feces. (After Leuckart, 18(i8, p. 494, fig. 276.)
. 74. Isolated embryo of Trichuris affinis. (After Leuckart, 1868, p. 495, fig. 277.)
83
FIG. 75. Egg of Cochin-China diarrhea worm (Strongyloides stercoralis) found in stools. (After Thayer,
1901, pi. 9, fig. A.)
FIG. 76. Rhabditiform embryo of same, from the stools. (After Thayer, 1901, pi. 9, fig. B.)
FIG. 77. Filariform larva of same derived, by direct transformation, from a rhabditiform embryo.
(After Thayer, 1901, pi. 9, fig. C.)
Figures 75 to 77 were drawn from life, as seen under Leitz, objective 7 ocular 3.
o .
FIG. 78. Egg of the common liver fluke ( Fasciola hepatica} examined shortly after it was taken from the
liver of a sheep; this is the same stage that is found in human feces; at one end is seen the lid or opercu-
lum, o; near it is the segmenting ovum ; the rest of the space is occupied by yolk cells which serve as
food ; all are granular, but only three are thus drawn. X 680. (After Thomas, 1883, p. 281, fig. 1.)
FIG. 79. Egg of the common liver fluke containing a ciliated embryo (miracidium) ready to hatch
out; d, remains of food; e, cushion of jelly-like substance; /, boring papilla; h, eye-spots; k,
germinal cells. X 680. (After Thomas, 1883, p. 283, fig. 2. )
FIG. 80. Embryo of the common liver fluke (Fasciola hepatica) boring into a snail. X 370. (After
Thomas, 1883, p. 285, fig. 4.)
FIG. 81. Egg of lancet fluke (Dicroccclium lanccatnm) with contained embryo. X 700. (After
Leuckart, 1889, p. 379, fig. 171.)
FIG. 82. Egg of human blood fluke (Schistosoma h.rmatobium) with contained embryo, passed in the
urine or in the feces. X 285. (After Looss, 1896, pi. 11, fig. 112.)
FIG. 83. Egg of beef-measle tapeworm (Tfenia saginata) with thick eggshell (embryophore), con-:
taining the six-hooked embryo (oncosphere) enlarged. (After Leuckart.)
FIG. 84. Eggs of pork-measle tapeworm (Ttrnia solinni): a, with primitive vitelline membrane; b,
without primitive vitelline membrane, but with striated embryophore. X 450. (After Leuckart,
1880, p. 667, fig. 297.)
85
MICROSCOPIC EXAMINATION OF FECES.
No special technique is necessary. Simply take a small amount of
;f eces, preferably from near the surface, about the size of the head of a
large pin; spread this out in a drop of water on an ordinary micro-
Lscopic slide and cover the preparation with a cover slip. Examine
under any moderately high power, as a Zeiss 8 mm., Zeiss C, or a
Biiusch & Lomb one-third inch. Look carefully, with not too strong
illumination, for an elongate oval egg with thin shell, and with proto-
plasm either unsegmented or in the early stages of segmentation. -The
older the f eces and the warmer the weather the more advanced will be
the segmentation. In case of infection with Uncinaria americana the
fully developed embryo may be found within the eggshell. Be cau-
tious not to mistake for the egg of the Uncinaria the eggs of Ascaris
lunibricoides, which have a thick gelatinous, often mammillated,
covering and an unsegmented protoplasm (figs. 43-44), or the eggs
(figs. 57-65, of Oxyuris vermicularis, with a thin
asymmetrical shell (one side being almost straight)
and containing an embryo, or the eggs of whip-
worms (Trichuris trichiura,, more commonly known
to physicians as Trichocephah^s dispar), possessing a
smooth, thick shell, apparently perforated at each
pole, and an unsegmented protoplasm (fig. 70).
As a rule, in fecal examination I prefer to use the
, , . , , _ , _ . , , . -, r , . , . FIG. 85. Egg of the
thick, large, 2 by 3 inch slide, such as is used in dw arf tapeworm (fly-
examining- for trichinae, rather than the ordinary 1 ^enoiepis nana) of
u oil,- u T? v u i-j rnu l VJ man - Greatly magni-
by 3 thin English slide." The larger slide is not fled. ( After B.H.Ran-
only more steadily and more easily manipulated som '
in case one is working without a mechanical stage, but it is much
cleaner to handle.
In most cases of infection with intestinal worms the simple method
just described will suffice for a positive diagnosis. Before giving
a negative opinion, however, I invariably make ten preparations
or follow a procedure which we may call " sedimenting the feces."
Experience has shown me that in cases of negative diagnosis by the
simple method positive diagnosis occasionally results if the feces are
washed and " sedimented."
Method of washing and sedimenting feces. -Take one or two ounces
of feces, fresh or dry, mix with water, and place in a large bottle,
retort, jar, or any other receptacle; add enough water to make from a
pint to two quarts, according to the amount of feces; shake or stir
thoroughly and allow to settle; pour off the floating matter and the
water down to near the, sediment; repeat the washing and settling
several times, or as long as any matter will float. The last time this is
done use a bottle or graduate with a smaller diameter, and when the
material is thoroughly settled examine the fine sediment. It will be
86
found that the eggs have settled more numerously iathe fine sediment
than in the coarse material.
In case an unusual amount of large coarse material is present in the
feces, it is sometimes convenient to pour the entire mass through a
sieve, rejecting the portion left in the sieve; or to wash the feces in a
sieve, holding the latter under water. As a rule, however, the sieve
is not very useful in fecal examinations.
The centrifuge does not appear to be of any special value in fecal
examinations.
If facilities are not at hand for making a microscopic examination,
about half an ounce of either perfectly fresh feces, or of rather dry
feces, may be placed in a bottle, preferably with a large neck, prop-
erly packed in a mailing case, and sent to any professional pathologist
or zoologist for examination.
GROSS EXAMINATION OP PECES.
If uncinariasis is suspected and it is not practicable either to make
a microscopic examination or to delay matters until a specimen can be
sent away for examination, still another method of diagnosis is possi-
ble. Give a small dose of thymol, followed by salts, and collect all of
the stools passed. Wash the stools thoroughly several times in a
bucket, and examine the sediment for worms about half an inch long,
about as thick as a hairpin or hatpin, and with one end curved back to
form a hook. If these are found, institute definite treatment.
TREATMENT OF HOOKWORM DISEASE.
ANTHELMINTHIC TREATMENT.
The two drugs most commonly used in uncinariasis are thymol and
male fern. The day before treatment the patient is placed on a milk
and soup diet for three days.
Thymol. The directions usually given for thymol treatment are
these: Two grams (31 grains) of thymol at 8 a. m. ; 2 grams (31 grains)
at 10 a. m. ; castor oil or magnesia at 12 noon.
One week later the stools should be examined, and if eggs are still
present, treatment should be repeated until the eggs disappear, but it
is not best to give the thymol more than one day per week. Some
cases of hookworm disease are quite obstinate and require a treatment
extending over several weeks. It is, therefore, an unfortunate error
to expel a few worms with one or two doses and then dismiss the
patient as cured without having made further microscopic examination
for eggs.
Sandwith (1894, p. 21) reports 42 men cured after a single dose; 58
after 2 doses; 43 after 3 doses; 25 after 4 doses; 9 after 5 doses; 4
after 6 doses; 2 after 7 doses, and 2 after 8 doses.
A number of writers, particularly Giles, Sandwith, and others,
agree that small doses of thymol are valueless, but Sandwith is of the
opinion that 4 grams in 24 hours are as efficacious as 6 grams, and the
former dose is certainly less dangerous.
Worms may be found in the stools as early as eight hours after the
first dose of thymol. In 50 cases Sandwith counted 1,301 worms in
stools passed within eight hours after the first dose and 444 worms
within the next sixteen hours. From his context, however, it is clear
that brandy was given to these patients (see below), hence the thymol
was dissolved more rapidly. Giles reports that he seldom found any
worms until twelve hours after the first dose of thymol. "Occasion-
ally patients vomited after swallowing thymol, but as a rule they
retained it perfectly," and u they used to ask for an extra dose of it
while convalescing. "
Sandwith goes on to say that "large doses of thymol have a poison-
ous effect on the system, not unlike those produced by carbolic acid.
The temperature is lowered one or even two degrees centrigrade, and
both pulse and respiration are slowed. The patient remains fora few
hours collapsed, giddy, and faint, and has to be kept lying down, but
at sunset he is quite well again and asking for food." He gives the
following as a typical case:
"January 14, 1892. 6 a. m., temperature 37.5, pulse 80, respiration 19; patient in
his usual state and was given 2 grams of thymol. 7 a.m., temperature 37, pulse
80, respiration 19; says he has slight nausea, giddiness, and colicky pains in the
epigastrium. 8 a.m., 2 grams more of thymol given. 9 a.m., temperature 35.5,
pulse 70, respiration 17; great giddiness, can not stand or walk; very sleepy, and
talks like a drunken or very sleepy man. 12 a. m., symptoms much the same; sweat-
ing while asleep. 2 p.m., temperature 37.5, pulse 75, respiration 18; apparently
quite w r ell again. Says he does not mind the thymol, except that it makes him lose
consciousness. ' '
Some authors advise the use of alcohol with thymol, others warn
against such use. Sandwith, in referring to this subject, says:
"Warned by the death of at least one of my patients immediately
after digesting the thymol, I have always administered to feeble men
25 grams of brandy with each 2 grams of thymol, with the happiest
results."
Authors who warn against the use of alcoholics during treatment do
so on the ground that thymol is soluble part for part in alcohol, hence
will more quickly be absorbed by the system. With one of my assist-
ants (see Stiles & Pfender, 1902a), in the Bureau of Animal Industry,
I treated a number of dogs with thymol in various forms. We gave
doses varying from 10 to 100 grains (0.648 to 6.48 grams) to dogs
weighing from 8 to 35 pounds. In alcoholic solution, 30 grains (1.94
grams) caused convulsions in a dog weighing 15 pounds, and severe
convulsions in one weighing 14 pounds; on the other hand, an 8-pound,
old dog suffered no ill effects after 30 grains in alcohol, and a 35-pound
88
dog took 75 grains (4.86 grams) in alcohol without deleterious effect.
In tablet form, without oil, a single dose of 100 grains (6.48 grams)
killed a dog of 15 pounds in four days; a dose of 50 grains caused a
12-pound dog to attempt to vomit; a dose of 75 grains was without
appreciable effect in a dog of 35 pounds; 30 grains were without effect
on a dog of 8 pounds; daily doses of 20 grains each caused a slight
diarrhea after six days in a dog of 15 pounds; the same dose caused a
17-pound dog to be quite sick on the sixteenth day. In tablet form,
with castor oil, 30 grains caused a 12-pound dog to attempt to vomit,
while doses of 10 and 20 grains were negative on dogs weighing 12 to
15 pounds. In powdered form, without oil, 20 grains caused a 12-
pound dog to attempt to vomit, while doses of 10 and 20 grains respec-
tively were negative in dogs of 12 and 15 pounds; 40 grains .caused no
ill effects in a dog of 8 pounds, and a dose of 80 grains was without
effect on a dog of 35 pounds. In powdered form, with castor oil, 20
grains caused slight convulsions in a dog weighing 15 pounds, but
doses of 10 and 20 grains were negative on dogs of the same weight.
Blue foxes to which we gave 3 grains in alcohol became quite sick.
Theobald states that a dose of 3 grains has produced partial prostra-
tion in a bull-terrier, but he does not give the weight of the dog.
According to Sand with, the contra-indications for thymol are " excess-
ive debility, very low temperature, age above 60, and advanced diseases
of the heart or any other organ. Boys take it very well in half quan-
tities."
Sandwith states (1894, p. 17), that of 8 fatal cases treated with
thymol 2 died, he thinks, in consequence of the thymol, eleven and
forty -eight hours, respectively, after taking the dose; both of these
men had previously had thymol without bad effect, but they were
both in a miserable state of exhaustion and debility. He does not
think that thymol accelerated the deaths of any of the remaining 6
cases, which occurred five, six, nine, thirteen, fifteen, and nineteen
days, respectively, after the last dose of thymol. Three of these cases
were over 65 years of age.
While my experience with thymol in man is very limited, I must
confess that from my experiments upon animals, I am afraid of the
use of alcoholics per os during treatment, and in the case of weak
patients I should be more inclined to use a stimulant hypodermically
than run the risk of dissolving the thymol too rapidly or in too great
quantity at one time. Furthermore, it is at least doubtful whether
our American hookworm will be so difficult to expel as is the Old
World species, because of the absence of the ventral hooks (cf. figs. 5
and 10) in Uncinaria amevicana.
In the case of "excessive debility" and other conditions which
Sandwith designates as contra-indications for thymol, it is not clear
what drug Sandwith would use, for he states (1894, p. 20) that "for
89
the last three years I have looked upon it as a waste of time to admin-
ister any other anthelminthic than thymol for this parasite " [Agchylo-
stoma duodenale\. Certainly persons in the conditions described should
not be allowed to go untreated, and despite the view advanced by some
authors, smaller doses of thymol, repeated one day per week and
extending over several weeks, may be expected to yield some results.
Male fern. Several European authors advise the use of large doses
of extract of male fern in treating hookworm disease. Eichhorst's
(1901, p. 314) recent "Practice" places the dose at 10 grams (2.5 fluid
drams) to 20 grams (5 fluid drams). It has been pointed out by Lepine
(1891a, 1891b) and others that such large doses of this drug are likely
to be followed by serious toxic symptoms and even by death. Lepine
summarizes the conditions as (1) symptoms of gastrointestinal irrita-
tion characterized by the redness and the hemorrhages; (2) nervous
symptoms (convulsions and paralysis); (3) albuininuria, and (4) glyco-
suria, and he warns not to give over 8 grams of the extract as a maxi-
mum dose. Hare gives the dosage of the extract as 4 to 8 grams
(about 1 to 2 fluid drams). Male fern should be followed in three to
four hours by a calomel purge, aided by a saline, but not by castor or
other oils, as the latter increase the danger of absorption, hence of
poisoning.
Calomel. While thymol is at present considered the most reliable
remedy in hookworm disease, indications are not lacking (see p. 76)
that considerable good may be accomplished in the American form of
the disease by the use of calomel. This drug will not, however, be
followed by such prompt and satisfactory results as will thymol.
GENERAL TREATMENT.
The administration of thymol has for its object the expulsion of the
parasite, hence the removal of the cause of the disease. This should
be supplemented by efforts to build up the depleted system by means
of good nourishing food, iron, etc. It is well to give the iron daily,
except on the days that thymol is taken. Sandwith (1894, p. 25)
claims that the blood was most benefited by a daily supply of 1.5 grams
(23 grains) of the sulphate of iron in water in three equal doses.
PROGNOSIS.
Among physicians I found the view rather prevalent that the prog-
nosis was poor for children who presented severe cases of the disease.
This view is probably due to the fact that the cause of the trouble
was not understood, hence treatment was not directed to removing
the cause.
The proposition now before us is, first, to remove the intestinal par-
asites, and second, to build up the patients.
90
To accomplish the first desideratum may require some patience, but
efforts will eventually be successful. The second point may also be
carried out, unless, of course, the patient is too far gone at the time
of treatment to recover from the effects of the disease.
In not all cases can it be expected that a dwarfed, emaciated, and
stupid child can be immediately placed upon the same physical and
mental basis as his brothers, but even such cases can be greatly
improved.
LETHALITY OF HOOKWORM DISEASE.
I know of no extensive and exact statistics regarding the lethality of
uncinariasis, and traveling as rapidly as I did, it was impossible to
establish any definite facts from personal observation, since it was the
exception that 1 saw any case more than once. Furthermore, owing
to the fact that many light cases will escape attention, any lethality
percentages published will probably be above the actual figures.
I doubt whether sufficient data are at hand to justify even approxi-
mate statements regarding the lethality of hookworm disease. That
numerous cases, not properly treated, terminate fatally can not be
doubted. Still, it is remarkable how low a person may be with hook-
worm disease and still live.
Among physicians I met with the most contradictory ideas on this
subject. Several excellent observers maintained that all severe cases
which reached an edematous condition were invariably fatal; equally
keen observers doubted whether this disease was frequently the actual
cause of death; the view was quite general that patients suffering from
medium or severe attacks of this malady very seldom lived through
even medium or light attacks of such diseases as typhoid fever, or
pneumonia, and that severe attacks of malaria were frequently fatal;
also that they were very uncertain patients in confinement.
In my own observations, several points seemed quite significant.
In the first place, the large number of cases of long standing found in
so many families did not indicate a high lethality. Further, several
adults were seen who had formerly unquestionably presented severe
infections, but who are now in a fairly good state of health. In one
family with 9 children living, most of whom clearly presented light,
medium, or severe infections, there was a history of death of 9 other
children, but satisfactory answers as to the cause of these deaths were
not obtained. That some of the children had died of uncinariasis is
very probable. On the other hand, families were seen with 8 to 10
children, all or nearly all in an anemic condition, some with clear
medium to severe cases of uncinariasis, yet without history of any
fatal case in the family. I have heard of localities in Central America
(but have not investigated them personally) where it is said that a dis-
91
ease, which from its description I believe to be uncinariasis, probably
due to Undnaria americana, causes an immense mortality among the
children.
Taken all in all, the data obtained did not convince me that uncina-
riasis, per se, is so fatal a disease in man as is generally supposed.
On the other hand, I obtained the impression that while very severe
cases are not infrequently fatal, the general effects of the malady
upon the system are of greater and more far-reaching importance than
the lethality of the infection itself. In other words, if uncinariasis
were eliminated, the lethal^ of other diseases, such as pneumonia,
typhoid fever, malaria, and also of child birth, would be decreased,
and in the sand and mixed sand and clay areas this decrease would not
be an insignificant factor.
One physician stated to me that he was confident that he had lost
several hundred patients from uncinariasis within the past forty
years.
Sandwith (1894, pp. 16-17) states that of the patients nominally
under his care, 89.5 per cent were cured or greatly improved, 2.5 per
cent were unrelieved, and 8 per cent died.
"Most of the fatal cases had loud anemic murmurs, marked subnormal tempera-
ture, slight general edema, albuminuria, and great mental weakness.
"The actual cause of death was exhaustion, from utter absence of rallying power.
It is difficult to believe that the pathological effects are induced only by hemorrhage
from the daily suction of scores or even hundreds of worms. .In addition to the
loss of blood, we have general thickening and degeneration of the duodenum and
jejunum, and consequent interference with normal digestion; then nonassimilation,
and eventually a process of slow starvation. It is also worthy of consideration that
there may be in prolonged cases some self-poisoning from the great number of bites
in the walls of the intestines containing ill-digested and perhaps decomposing food."
POST-MORTEM APPEARANCES.
1 did not have occasion to make any autopsies during the trip;
hence I am unable to present any original observations in this line.
For careful accounts of single cases of autopsies, the reader is referred
in American literature to Strong (1901), Yates (1901), Claytor (1902a),
and Capps (1903a).
Sandwith's (1894, pp. 17-20) summary of 26 autopsies is not acces-
sible to many American physicians; hence it is quoted here in full.
"Some of the earlier autopsies were made by myself, the later ones by Dr. Kauf-
mann. The muscles w r ere in one case described as of normal color, but in all others
they were very pale. There was usually a great absence of subcutaneous fat. The
lungs were very pale and edematous in all cases, and all the organs were extremely
bloodless.
"In one case there was noted edema of glottis. The heart was found to be hyper-
trophied ten times [in 10 cases], and was very small twice! generally pale brown
in color, and on three occasions there were marked changes in the mitral valve.
The most common abnormality in the liver was a brownish-yeliow fatty appearance.
92
In one case there were several abscesses and the liver weighed 3,700 grams, and in
one patient there was well-marked jaundice.
"The spleen was enlarged in one-third of the post-mortems. The kidneys invari-
ably showed some change, though this was often much more marked in one kidney
than in the other. They were very pale in 24 patients, 3 of whom had several
small cysts. Of the remaining 2 patients one had granular kidneys and the other
had cysts, but the kidneys were of normal color.
"The brain was always exceptionally white, and in one case there was recent
apoplexy.
"The small intestines showed, of course, the most important changes. As a rule,
there were many hemorrhages and bites in the jejunum and ileum, but in one of the
cases where the bites were carefully counted there were only 6 in the jejunum and
ileum, and no worms were found. In another case, however, there were 575 bites
in the small intestine, besides 250 anchylostoma. In yet another there were 100
bites, the farthest of which was 4.5 meters from the pylorus. In only two cases
was there much liquid blood in the intestine.
"I have not observed the constant changes in the mucous membrane of the stomach
described by Giles. The great variability in the number of anchylostoma found at
the autopsies is interesting. In 7 cases, all treated by thymol during life, no worms
could be found. In an eighth case, also treated by thymol, but insufficiently, there
were 10 worms. The remaining 18 cases had not had the advantage of thymol. Six
of them, nevertheless, were found to have less than 10 worms, and in two of these
corpses only 1 worm was found in each jejunum. Three other cases numbered 20,
40, and 50 worms, but the remaining 9 had numbers varying from 170 to 381, termi-
nating with the maximum record of 863. On that occasion the autopsy was made
seven hours after death, and the worms were scattered from a point 1 inch beyond
the pylorus for the length of 3 meters; 217 of the 863 were attached still to the intes-
tine and were surrounded by much bloody mucus, while 646 were lying free in the
intestine; 16 of the latter were still alive, and one couple were in copulation.
' ' Next the position of the worms deserves notice. It was quite the exception to find
any parasites in the duodenum. Can it be that when the duodenum becomes thick-
ened and riddled, as it were, with the ravages of former generations, the anchy-
lostomum fastens by preference on to the jejunum? Some such cause as this
suggestion of gradually shifting the pasture is required to explain the interesting fact
that it is not the most advanced cases of anemia which will always yield the largest
quantity of worms. In such cases the parasite must not only have to burrow extra
deep, but the blood when reached is, of course, deficient in quantity. Or is it that
the half-starved worms are dislodged by repeated attacks of diarrhea? The furthest
feeding ground that I have seen was 6.30 meters from the pylorus, where there was
a worm firmly attached. But, as a rule, the attached worms are all within 2 meters
of the pylorus, and have their heads and sometimes half their bodies buried in the
mucous membrane. It is often impossible to dislodge them by a strong stream of
water, and they must then be pulled out by forceps.
' ' I examined about 50 cases to see the proportion of male to female worms, and
found it 56 to 44 per cent. This is not in accordance with some of the authorities,
who say that males are always more rare than females, and that males are less
influenced than females by the action of expellent drugs."
a "Dubini has only once seen the worm in the ileum. The nearest feeding ground
seen by me was 24 centimeters from the pylorus. In that case there were 100 worms
attached and 281 detached, besides oxyurides."
93
PREVENTION OF HOOKWORM DISEASE.
Iii llir prevention of diseases caused by animal parasites, we may, of
course, attempt to attack the infectious agent in any stage of its life
history. In connection with uncinariasis, three periods in particular
come into consideration, namely: (1) The adult worm in the intestine;
(-2) the egg in the feces, and (3) the infecting ("encysted") stage of
the larva.
(1) ADULT WORM IN THE INTESTINE; TREATMENT.
The destruction of the adult worm in the intestine not only relieves
the patient of an important and (when present in large numbers)
serious or even dangerous parasite, but it is also an important factor
in preventing the spread of the disease to other people. Accordingly,
treatment should be instituted even if the eggs found in the feces are
so few in number as to indicate only a light infection.
Not infrequently the opinion is expressed that the infection with
parasites found in a given patient is so light that treatment is hardly
necessary. Such a view, however, is often very shortsighted, for it is
not infrequently light infections occurring at unfavorable seasons and
under unfavorable conditions that furnish the material for heavy
infections at more favorable times. No Uncinaria infection in man
is too light to be worthy of treatment, for each adult female may lay
eggs; hence the destruction of these females means the decrease of
scores of free infectious larvae.
Not all cases of the malady can be recognized without the micro-
scope; hence many people will unconsciously spread the disease-
producing agent. Furthermore, many cases which might be recog-
nized by symptoms will not come under medical treatment, so that
they, too, will spread the infectious material. It is clear, therefore,
that for satisfactory results in prevention we must adopt some method
in addition to the treatment.
(2) EGGS IN THE FECES | CONTROL AND DESTRUCTION.
It is in the feces that we find the potentially infectious material in
the most concentrated form. After the eggs develop into embiyos
the latter may leave the fecal matter and be distributed in the sand or
in the water. Accordingly, it is much easier to control or destroy 'a
given amount of infectious matter while it is concentrated in the
feces than it is later when it is spread over a larger area. Here, in
fact, we have the key .to the prevention of uncinariasis. Proper dis-
posal of the fecal discharges will make the spread of uncinariasis
impossible. As such proper disposal I will suggest: Properly built
privies when sewerage is lacking; use of such outhouses after con-
struction; cleaning the same at regular intervals, and burial, burning,
disinfection, or drying of the feces.
(3) THE INFECTING ( ' * ENCYSTED ") STAGE OF THE LARVA.
Disinfection of premises. A chemical disinfection of premises to
kill the free stages of eggs, embryos, and larvae of the parasite would
hardly be practicable, but heat, dryness, and cold all result in killing
these organisms.
95
About twenty-four to forty-eight hours of freezing temperature
kills the free infection, hence after any cold weather of this kind in
winter it may be assumed that the premises are disinfected.
After any especially dry weather, most if not all the free infection
(except such as exists in places not affected by the dryness) is killed,
so that exposed portions of premises may be assumed to be practically
disinfected.
Spraying- with burning oil (fig. 86), as practiced by the Massachusetts
Gypsy Moth Commission, will effectually disinfect any area. If a
spray nozzle or "cyclone burner" is not at hand, the ground around
the house could be strewn with straw or brush and set afire (due pre-
caution being taken not to burn the house), thus thoroughly disinfecting
the premises. (See Stiles, 1902 d.)
Drinking water. To tell the average farm hand or miner that he
should always "boil or filter" the water before drinking it is, academ-
ically, a step toward preventing infection with uncinariasis. Practi-
cally, however, it is a step toward throwing away whatever influence
we may happen to have with him. Theoretical^, we should teach this
simple hygienic precaution to all families, both in the city and in the
country. Practically, we are in many cases weakening our position
by insisting too generally upon this point.
While, therefore, we may warn people to boil or filter their
drinking water in order to prevent the introduction of the infecting
agent of uncinariasis or of other diseases, provided we see any chance
of their following the advice (in regard to which we ourselves, except
in times of epidemics, are very inconsistent), we will, I believe,
usually weaken our influence with the poorer classes in mentioning
a precaution which the average farm hand naturally looks on as
absurd. It is much more important to urge him to locate his privy
some distance from the well. That is a proposition he can appreciate;
the necessity for boiling or filtering drinking water is usually beyond
his mental horizon.
Clean hands. An important point in connection with preventing
the ingestion of the infectious agent of uncinariasis is that the hands
and finger nails should be kept clean. I am inclined, however, to take
an ultrapractical view of cleanliness versus dirt in connection with
country houses, and to first see that the inevitable dirt shall be clean
This can be accomplished if we can succeed in having properly con-
structed latrines, built at proper distance from the wells and houses,
if the children be taught to use them, and if the parents be taught the
necessity for cleaning them.
These, in my opinion, are the first steps to be taken, and far out-
weigh all such considerations as boiling and filtering drinking water
or keeping the hands clean.
Wearing shoes. Wearing shoes during wet weather and washing the
feet frequently will prevent the cutaneous infection and will protect to
96
a great extent against ground itch. It can hardly be expected, how-
ever, that the poorer children in country districts will adopt this
precaution to any extent.
COMMON INTERPRETATION OF HOOKWORM DISEASE.
Upon several former occasions I have referred to "cases of anemia
of obscure origin" as possibly due to uncinariasis. In a recent paper
(Stiles, 1902b, pp. 207-208) I referred to ' ; dirt-eating " as being possibly
connected with uncinariasis; it was also intimated (1902b, p. 215), upon
authority of Dr. Kirby-Smith, that in Mississippi uncinariasis is con-
fused with malaria; Harris (1902c) also points out that much of the
anemia attributed to malaria and dirt-eating is probably due to hook-
worm disease.
At present I am able to make more specific statements than for-
merly. The condition which should be attributed to light infections
of uncinariasis is usually interpreted as due to malaria or diarrhea;
medium cases are usually interpreted as an anemia due to malaria
combined with "improper diet" or "insufficient nourishment;" severe
cases are usually attributed to "malarial cachexia," "dirt-eating,"
"resin-chewing," "heart disease," "dropsy," "general debility,"
"pernicious anemia," and "lack of proper nourishment." Such at
least are the most common diagnoses which have been made by the
attending physicians in the cases which I have interpreted as light,
medium, or severe infections with Uncinaria americana.
ECONOMIC IMPORTANCE OF HOOKWORM DISEASE.
Malaria is admittedly one of the most important diseases when
viewed from an economic standpoint. In general, uncinariasis is, in
the South, fully as important as malaria, and in some respects it is of
even greater importance.
Take a given farming area in the sand district with an infection of
uncinariasis, and assume that 100 farm hands are employed. It is not
an exaggeration to say that these 100 people are not doing the work
of 80 or 90 average hands. Thus there is a distinct loss of 10 to 20
per cent in the wages and a corresponding loss in the crop returns.
In some places I should estimate the loss at even a higher percentage,
say an average of 25 per cent, while in several families which I have
examined I should say that uncinariasis is reducing the laboring
capacity, hence the productiveness, of the family to as low as 30 to 40
per cent, thus entailing a loss of 60 to 70 per cent.
Nor are the losses in wages and in the laboring capacity, and the
decrease of productiveness of the family, hence of the farm, and finally
of the county and State, the only economic considerations involved.
Cases are not unknown where families have sold, moved, or destroyed
their homes, or were about to do so, because of the existence of this
disease and because of the belief that it might be due to the locality
in which they lived.
97
Again, it is almost a common experience to be told by the father
of a family that he spends for medicine all he earns, in the hope of
ridding his children of this malady. Add to this the physicians' bills,
the loss by death and funeral expenses, etc., and it is seen that this
infection is keeping more than one family in absolute poverty.
Nor should we forget that unciriariasis has its important bearing
upon the mental as well as upon the physical and financial development
of the poorer white people. As already stated, children infected with
this malady are often underdeveloped mentally; frequently they have
a reputation in the schools, in the neighborhood, and in their own
family, of being " stupid," or "dull," or " backward" in their studies,
etc. It has already been mentioned that children suffering w.ith this
disease are frequently kept home from school because of their tendency
to become edematous when they sit still for any length of time.
When we now recall that these conditions coincide especially with the
educational period, it should not seem strange that uncinariasis has a
marked influence upon the general intellectual condition of the dis-
tricts in which it occurs.
Considering the subject in the light of all I saw on the trip, and
taking what I believe to be a conservative view of the subject, I find
it exceedingly difficult to escape the conclusion that in uncinariasis,
caused by Uncinaria americana, we have a pathologic basis as one of
the most important factors in the inferior mental, physical, and financial
condition of the poorer classes of the white population of the rural
sand and piney wood districts which I visited. This sounds like an
extreme statement, but it is based upon extreme facts.
By this position I do not intend to assert that uncinariasis is the
only factor which comes into consideration. The warm climate and
the monotonous diet, and probably also the excessive use of tobacco
in some cases, are not without influence. Still, with uncinariasis as it
exists to-day, these people are suffering from a handicap in life which
practically removes them from a fair chance in competition. If the
uncinariasis is removed they will be placed in a more favorable con-
dition both subjectively and objectively. With the present prevalence
of uncinariasis their lack of ambition is perfectly natural; remove the
disease and they can develop ambition.
On the other hand, if we were to select the strongest people in the
country and place them in the conditions under which these patients
are now living it would be only a generation or two before even a
race of athletes would be in the same condition as the persons under
discussion.
The conditions described are familiar to persons who have visited
the rural sand districts. But they have existed for so many years that
many of us to-day look upon them as natural, hence they do not
attract the consideration to which they are entitled.
19558 No. 1003 7
98
GEOGRAPHIC DISTRIBUTION AND ABSTRACTS OF CASES FOUND IN
THE UNITED STATES.
In a former paper (Stiles, 1902b, pp. 206-217) I gave abstracts of
all the cases of uncinariasis known to me at that time for the United
States. The disease is now proved to be so common in certain por-
tions of the country that it is hardly necessary to keep a full record of
every case found, but on account of the medico-historical interest asso-
ciated with the subject, and also in order to complete the literature and
details of geographic distribution, there are here added abstracts and
notices of various cases which have come to my knowledge since the
above-mentioned paper was completed.
NEW ENGLAND STATES.
NEW HAMPSHIRE.
No positively diagnosed cases of hookworm disease seem to be
recorded for this State.
Center Eppingham, 1876 - ? 1 case, ? death.
GOULD (1876, pp. 417, 418) refers to a case of pica or dirt-eating which sounds sus-
piciously like uncinariasis.
MIDDLE STATES.
NEW YORK.
Rochester, 1868 . . - ? 1 case, ? death.
ELY (1868, pp. 101, 102) describes a case of chalk-eating which may possibly have
been due to uncinariasis, though this is by no means certain.
Buffalo, 1896 _ _ . .5 cases, death.
MCEHLAU'S (1897) cases. See STILES (1902b, p. 209). Doubts have arisen in the
minds of some physicians as to whether these were actually cases of uncinariasis.
Glen Island, 1900 _ . A cases, death.
ASHFORD'S cases from Porto Rico. Probably due to Uncinaria americana; reported
in STILES (1902b, p. 210).
Stapleton_ __1 case, death.
BAILHACHE'S, and GREENE'S (1901) case. Place of infection uncertain. See STILES
(1902b, p. 215).
Albany, 1900. .-1 case, death.
WARD (1902, pp. 23-26): American, physician, 32 years old. Had served inU. S.
Army in the Philippines. Albany hospital, Feb. 6, 1902. Report on feces by Dr.
GEORGE BLUMER, confirmed by Dr. W. S. THAYER.
? Albany, 1900. . . .1 case, death.
NEUMAN and BLUMER. Details of case not known to me.
99
PENNSYLVANIA.
It is by no means impossible that uncinariasis will be found among
the miners of Pennsylvania. As so many of these men are immigrants
from Europe, the Old World species, Agchylostoma duodenale may be
expected.
Philadelphia, 1900-1901 _ . 3 cases, death.
BOSTON'S cases reported by ALLYN and BEHREND (1901). See STILES (19Q2b, p. 211).
Probably due to Uncinaria americana.
Philadelphia, 1901 _. - 1 case, death.
ALLYN and BEHREND' s (1902) case, imported from Italy, hence due to Agchylostoma
duodenale.
MARYLAND.
Baltimore, 1900 . 2 cases, death.
HEMMETER'S (1902) cases; probably infected in Porto Rico and due to Uncinaria
americana. See STILES (1902b, p. 210).
Baltimore, 1901 1 case, 1 death.
HALL'S (1901) case; imported, possibly from Vera Cruz. Due to Agchylostoma
duodenale. See STILES (1902b, pp. 213-215).
Baltimore, 1902 _ . , 1 case, death.
OSLER'S case [unpublished]. In Johns Hopkins Hospital. Patient came from
North Carolina. Parasites determined by Boggs as Uncinaria americana, confirmed
by Stiles.
DISTRICT OF COLUMBIA.
Washington, 1901 __-[! case, 1 death.]
CLAYTOR'S (1901a, 1902a) case, from Westmoreland County, Va., due to Uncinaria
americana. See STILES (1902b, pp. 211-212) .
Washington, 1902 1 case, death.
HERRICK (1902, p. 101): Male, 37 years old, lived in Germany until 1897. Sent to
Philippine Islands September, 1899. " Present illness began in July, 1900, with an
attack of diarrhea. He had from 10 to 15 movements daily for three months, with a
moderate amount of tenesmus. Mucus and blood appeared in the stools after the
first month, giving them a dark tarry appearance. He lost weight and strength
rapidly during this time and gradually became short of breath on slightest exertion.
This was followed by a period of improvement, the stools becoming less frequent; but
in January, 1901, he became worse and was sent to the hospital at Iloilo. Since then
he has been confined to hospitals, on account of weakness and dyspnea. In Septem-
ber, 1901, the diarrhea ceased, and although he has gained a little weight he has been
steadily growing weaker. At no time had he been subject to hemorrhages other
than stated.
"Physical examination shows an apparently well-nourished man with a peculiar
lemon-yellow pallor; conjunctivas and mucous membranes are pale; slight oedema of
the ankles is present. He has marked dyspnoea on the slightest exertion. The lungs
are negative; the heart is enlarged; the point of maximum impulse is in the fifth
intercostal space in the nipple line. A soft blowing systolic murmur is audible at
the apex and in the pulmonic area. Liver dullness extends from the sixth intercostal
space in the nipple line to 1 cm. below the costal margin. The edge is palpable. The
spleen is enlarged and the edge is palpable at the costal margin. The urine is negative.
100
"The blood is very pale and watery; a moderate poikilocytosis is present; there
are no nucleated red corpuscles and no malaria organisms present. The blood count
shows: Bed corpuscles, 1,120,000; hemoglobin, 18 per cent; leucocytes, about 4,000;
polymorphonuclear, 52 per cent; eosinophiles, 26.8 per cent; small inononuclear, 14
per cent; large mononuclear, 4.4 per cent; transitional, 2.8 per cent.
"One month later, the patient meantime having been taking arsenic and iron, the
blood count was as follows: Ked corpuscles, 1,450,000; hemoglobin, 22 per cent; leu-
cocytes, 2,000; polymorphonuclear, 61 per cent; eosinophile, 18.2 per cent; small
mononuclear, 16.4 per cent; large mononuclear, 3.2 per cent; transitional, 1.2 per
cent; no nucleated red cells.
"There had been practically no change in the patient's condition. The liver and
spleen were as in the former note, and the dyspnoea was marked. Numerous typical
ovums of the Uncmaria were present in the stools, but no adult forms were seen.
After the usual thymol treatment about 60 adult worms were found. They resembled
in all respects Uncmaria duodenalis, and were identified by Dr. Stiles as the Old
World hookworm. The ovums present were in the progress of segmentation, 4 to 12
cells being visible. None were seen containing an embryo, as frequently occurs in
the form Uncinaria americana, described by Dr. Stiles.
"Blood examinations, ten and twenty days after the thymol treatment was begun,
showed the following counts:
I
May 28, 1902. June 7, 1902.
Red corpuscles
2 300 000 3 100 000
Hemoglobin
.... . . . per cent
'23 '27
Leucocytes. .
number
2 500 3 000
Polymorphonuclear
per cent.
54 62
Eosinophile
.do
21 14
Small inononuclear .
do
17 17
Large mononuclear
do
6 6
Transitional
do.
2 1
"The general condition is also improving rapidly, although the parasites are not
entirely eliminated, as an ovum is still occasionally found in the stools."
Anacostia (Government Hospital for the Insane), 1902 _ 16 cases, death.
Cases found on microscopic examination by Stiles, Garrison, Ransom, and Steven-
son, of United States Public Health and Marine-Hospital Service. Probably most
if not all of these were infected in other localities. (See p. 37.)
VIRGINIA.
Essex County, ? date g cases, ? deaths.
Passed Asst. Surgeon JOHN F. ANDERSON has stated to me that there exists in Essex
County a condition of ' 'bloat' ' and anemia which is usually attributed to dirt-eating,
and which corresponds in general to the conditions described in this paper.
Richmond, 1852 . . . _ ? 1 case, death.
POLLARD (1852, p. 185) reports a case of dirt-eating. Its connection with uncina-
riasis is possible, but not clear.
Richmond, 1898 1 or 2 cases, death.
GRAY'S (1901) case. See STILES (1902b, p. 209).
Westmoreland County, 1901 1 case, 1 death.
CLAYTOR'S case. See District of Columbia.
Westmoreland County, ? date 2 cases, death.
Referred to by STUART in STILES (1901, p. 525, and 1902b, p. 212).
101
NORTH CAROLINA.
Judging from the size of the eggs, all the cases I found in North
Carolina were due to T7ncinaria americana.
Roanoke River Valley, prior to 1808 :.\ cases, ? deaths.
PITT (1808) states that malacia or dirt-eating "prevails mostly among the poorer
white people and negroes, and originates in my opinion from a deficiency of nourish-
ment." He refers also to the slowly healing ulcers on the legs, and to the ''tallow
complexion." His general description points quite distinctly to uncinariasis.
Person County, 1832 ? cases, ? deaths.
JORDAN (1832, pp. 18-30) gives a discussion of dirt-eating which quite positively
refers, at least in part, to uncinariasis.
Durgy, Person County, 1902 . _ 2 cases, death.
STILES (1903b, p. 38).
Cumnock Coal Mines, Chatham County, 1902 Tease, death.
STILES (1903b, p. 38).
Gaston County, about 1880 ? cases, ? deaths.
The following interesting letter has been received from Dr. Barringer, and indi-
cates the presence of uncinariasis in Gaston County:
"DEAR SIR: I have just seen in the Marine-Hospital Service Public Health Reports
your letter of October 22, from Kershaw, S. C. I was for many years located in the
district in which you have been working, and your letter has thrown an immense
amount of retrospective light on what I saw there. My w r ork was done in the early
eighties, and yet I still remember many cases of pernicious anemia, which was accom-
panied in some cases by dropsical effusions and diarrhea, a combination I could
never make out, and yet this must have been uncinariasis.
"Whole sections of the illicit distillers of Kings Mountain, in Gaston County, N. C.,
were affected, and the dirt-eating whites of this section seemed to have a malady dif-
ferent from those of the better class in the neighborhood. I tried a tannic acid
preparation, which seemed to do more good than anything else, and I wish now I
had tried Areca nut. By the bye, I also recall that my pointer dogs in this section
seemed to be afflicted in the same way. During my stay in Gaston County, from
1878 to 1881, I lost two dogs, who used to follow me around to these houses, from an
unknown disorder.
' ' I remain, yours, very respectfully,
"P. B. BARRINGER, Chairman.
"Dr. CH. WARDELL STILES,
' ' Care Marine-Hospital Service, Washington, D. C. "
SOUTH CAROLINA.
Judging from the measurements of the eggs, all the cases I found
in South Carolina were due to Uncinaria americana.
Date ? ? cases, ? deaths.
HEUSINGEB and GEDDIXGS, quoted by BLANCHARD, 1888a, could not be traced.
Adams Run, Colleton County, 1902 4 cases, death.
STILES (1903b, p. 41): Orphans at Charleston.
102
Barnwell County, 1902 . _ .1 ease, death.
STILES (1903b, p. 41): Medical student at Charleston.
Berkeley County, 1902 _ _ . 3 cases, death.
STILES (1903b, p. 41): Orphans at Charleston.
Camden, Kershaw County, 1902 . . i _ _2 cases, death.
STILES (1903b, p. 39): Brickyard. '
Charleston, Charleston County, 1902 _ __ __3 cases, death.
Dr. DE SAUSSURE, quoted by STILES (1903b, p. 41): Source of infection not stated.
Charleston County, 1902 _ . __2 cases, death.
STILES (1903b, p. 41): Medical students at Charleston; came from seacoast islands.
Charleston, Charleston County, 1902_ _ __[15 cases, death.]
STILES (1903b, p. 41): At orphan asylum. Children came from Dorchester (1),
Berkeley (3), Colleton (4), and Charleston (7) counties
Charleston, Charleston County, 1902 _. _ .[4 cases, death.]
STILES (1903b, p. 41): Medical students from Barnwell (1), Florence (1), and
Charleston (2) counties.
Florence, Florence County, 1902 1 case, death.
STILES (1903b, p. 41): Medical student at Charleston.
Lancaster and Kershaw counties, 1902 about 50 cases, death.
STILES (1903b, pp. 40-41).
McClellanville, Charleston County, 1902 _ . 4 cases, death.
STILES (1903b, p. 41.) : Orphans at Charleston.
Plum Island, Charleston County, 1902 3 cases, death.
STILES (1903b, p. 41): Orphans at Charleston.
Summerville, Dorchester County, 1902 1 case, death.
STILES (1903b, p. 41): Orphan at Charleston.
GEORGIA.
Judging from the size of the eggs, all the cases I found in Georgia
were due to Uncinaria americana. Harris states that his cases were
due to the same species.
Locality ? Date ? ? cases, ? deaths.
LYELL quoted by BLANCHARD (1888a), could not be traced.
Richmond County, 1836 . _ ? cases, ? deaths.
COTTING (1836a, pp. 288-290) states that clay is eaten by many people, especially
by children. Probably at least some of the cases were connected with uncinariasis.
Pine Barrens of Georgia, 1845 . . ? cases, ? deaths.
LECONTE (1845, pp. 417-444) states that dirt-eating is common in the pine barrens
of Georgia. His description refers quite clearly to uncinariasis, at least in part.
103
Appling County, 1902 _ _.l case, ? death.
HARRIS (1902a, pp. 99-100) : Male, farmer, 29 years old. Healthy until 14 years of
age, then observed that he was never go well in latter part of winter and spring as
in summer and fall. Anemic; weak; food tastes salty; in spring the arms, hands,
and dorsal surface of feet become greatly inflamed, blisters form, followed by scabs;
severe constipation; pains in neck and stomach; vomiting frequent; weight 117
pounds; skin pale and wrinkled, smooth and dry; very little beard; mucous mem-
branes very pale; tongue moist, shows indentations of teeth, and its epithelium in a
large measure absent; teeth small, quite a number of them decayed; pulse 90, res-
piration 20, temperature 98 F.; body somewhat emaciated; heart with soft, blowing
systolic murmur constant, varying greatly in intensity; marked venous hum over
right jugular; just below the ensiform cartilage and to the left great tenderness;
stomach normal in size and position; after Ewald trial meal, total acidity 64, HC1
40, combined HC1 4, phosphates 4; spleen and intestines normal; feces dark brick-
red; Uncinaria eggs present; urine 2,300 cm. in twenty-four hours, light yellowish-
red; specific gravity, 1.012, faintly alkaline, no sugar, at one time faint ring of
albumin, albumose not present; urea in twenty-four hours, 21.15 grams, uric acid
0.475 gram, chlorids 3.15, phosphates 2.37, sulphates 2.82 grams. Blood: Red cor-
puscles 1,760,000, white 4,020, hemoglobin 20 per cent; decided though not extreme
poikilocytosis, a number of 'microcytes; a few nucleated reds; small lymphocytes 28,
large lymphocytes 14, transitional 6, polymorphonuclear leucocytes 50, eosinophiles
2. Vision, right eye 15-20, left eye 15-30. Diagnosis: Anchylosfomiasis and pos-
sibly pellagra. Treatment: Afternoon, 10 grains of calomel; next day, 7 a.m., 30
grains of thymol in capsules; 9 a. m., 30 grains of thymol; 8 p. m., large dose of salts.
Stools contained at least 420 worms. HARRIS, 1902b, pp. 220-227. Same case.
Porter Springs _ . A cases, death.
Letter of H. F. HARRIS, dated August 9, 1902, to IT. S. Bureau of Animal Indus-
try. He states: " I am absolutely sure that this disease is very common in all this
region." One of the four cases probably originated in Troup County, the other
three in Lumpkin or neighboring county.
Locality ?, 1902 . __7 cases, death.
HARRIS (1902c, p. 776) states that since reporting his first case he has discovered
eleven new cases for Georgia. See also Porter Springs.
Atlanta, 1902 _ _ 1 case, 1 death.
CLAUDE A. SMITH (1902, p. 1062): Case reported; mentioned also a similar case in
a dog which had eaten some of the infected feces of the patient. Man died of pleu-
ritic abscess. The specimens were collected post-mortem in a negro at Grady Hos-
pital, Atlanta.
Dr. Smith kindly sent me the parasites for examination. The specimens from
man (B. A. I., No. 3423) proved to be Uncinaria americana, while those from the
dog (B. A. I., Nos. 3424 and 3425) were Agchylostoma caninum.
Atlanta, November, 1902 _ _ _2 cases, death.
CLAUDE A. SMITH informed me in a personal letter dated December 3, 1902, that
he had just observed two cases, both from Florida. One was a man 50 years old,
the other a dental student.
Albany, Dougherty County, 1902 about 5 cases, death.
STILES (1903b, p. 43): People did not belong in Albany.
Americus, Sumter County, 1902 1 case, death.
STILES (1903b, p. 41) : Orphan in Macon.
104
Baxley, Appling County, 1902 _ . . . ,1 case, death.
STILES (1903b, p. 42): Orphan in Macon.
Buena Vista, Marion County, 1902 2 cases, death.
STILES (1903b, p. 41): Orphan in Macon.
Cordele, Dooly County, 1902 _ ._! case, death.
STILES (1903b, p. 42): Orphan in Macon.
Darien, Mclntosh County, 1902. _ lease, death.
STILES (1903b, p. 42): Orphan in Macon.
Effingham County, 1902 _ . 1 case, death.
STILES (1903b, p. 42): Orphan in Macon.
Fort Valley, Houston County, 1902 50 cases, death.
STILES (1903b, p. 42) : Dr. BROWN stated he could easily find 50 or more cases. We
examined about 10 cases together.
Jackson County, 1902 ? cases, ? deaths.
Dr. HARDMAN, quoted by STILES (1903b, p. 41).
Johnson County, 1902 . . 1 case, death.
STILES (1903b, p. 42): Orphan in Macon.
Jones County, 1902 4 cases, death.
STILES (1903b, p. 42): Orphan in Macon.
Kinderlou Station, Lowndes County 1 case, death.
STILES (1903b, p. 42): Orphan in Macon.
Lee County, 1902 _ _ _ . - 4 cases, death.
STILES (1903b, p. 43): Observed with Dr. HILSMAN.
Lyon, Tattnall County, 1902 .. .-1 case. death.
STILES (1903b, p. 42): Orphan in Macon.
Macon, Bibb County, 1902. . -.[29 cases, death.]
STILES (1903b, pp. 41-42): At orphan asylums. See Americus (1), Baxley (1),
Buena Vista (1), Cordele (1), Darien (1), Effingham (1), Johnson (1), Jones (4),
Kinderlou (1), Lyon (1),' Monroe (1), Rich wood (2), Sandersville (1), Thomas-
ville (1), Savannah (1), Waycross (3), Monroe (1), Georgia. Also: Deland (4),
Liveoak (1), Wacissa (1), Florida.
Macon, Bibb County, 1902 . _ . about 25 to 30 cases, death.
STILES (1903b, p. 42): About 25 to 30" cases; men, women, and children in the
cotton-mill families.
Monroe County, 1902 ______ 1 case, death.
STILES (1903b, p. 42): Orphan in Macon.
Richwood, Dooly County, 1902 2 cases, death.
STILES (1903b, p. 42): Orphan in Macon.
Sandersville, Washington County, 1902 1 case, death.
STILES (1903b, p. 42) : Orphan in Macon.
105
Savannah, Chatham County, 1902 . ..1 case, death.
STILES (1903b, p. 42): Orphan in Macon.
Thomas ville, Thomas County, 1902__. -..I- case, death.
STILES (1903b, p. 41): Orphan in Macon.
Washington County, 1902 - . - ? cases, death.
In personal conversation with Dr. A. MOODY BURT, I was informed that there were
a number of persons in Washington County who show in general the symptoms of
uncinariasis.
Waycross, Ware County, 1902 -3 cases, death.
STILES (1903b, p. 42): Orphan in Macon.
Waycross, Ware County, 1902_-._. _ . .-.I cases, ? deaths.
STILES (1903b, p. 43): Many cases, number not estimated ; about 20 cases of uncina-
riasis to 1 of malaria; on authority of Drs. IZLAR and WALKER.
Willacoochee and vicinity, Coffee County, 1902. .200 cases, death.
STILES (1903b, p. 43): Given on authority of Dr. WILCOX. We examined 8 cases
together.
FLORIDA.
Judging from the size of the eggs all the cases I found in Florida,
so far as examined microscopically, were due to Uncinaria americana.
Prior to 1845 ? cases, ? deaths.
LITTLE (1845) refers to dirt-eating; see STILES (1902b, p. 208).
Locality ?, 1902 - - ? cases, ? deaths.
GUITERAS'S cases; see STILES (1902b, p. 215).
Locality ?, 1902 - - -1 case, death.
HARRIS (1902c, p. 776) : Locality not given; originated in Florida.
Baker County . . . ? cases, ? deaths.
In personal conversation with a Jacksonville druggist, I was informed that so-called
dirt-eaters are common in Baker County.
Clay County ? cases, ? deaths.
In personal conversation with a Jacksonville druggist, I was informed that so-called
dirt-eaters are common in Clay County.
Deland, Volusia County, 1902. _ -.4 cases, death.
STILES (1903b, p. 42): Orphans in Macon, Ga.
Jacksonville, Duval County, 1902 2 cases, Okdeath.
STILES (1903b, p. 44).
Li veoak, Suwanee County, 1 902 - 1 case, death.
STILES (1903b, p. 42): Orphan in Macon, Ga.
Tampa, Hillsboro County, 1903 _ . _ - - - -12 cases, death.
In a letter dated March 21, 1903, Dr. J. S. HELMS says: "I have to date collected
12 cases and am yet working. I dare say that there are hundreds of cases in south
Florida." The parasites were Uncinaria americana.
106
Wacissa, Jefferson County, 1902 . . 1 case, death.
STILES (1903b, p. 42): Orphan in Macon, Ga.
Ocala, Marion County, 1902 5 cases, death.
STILES (1903b, p. 44).
Twiggs County, 1902 '. ? cases, U deaths.
I have been informed that in Twiggs County there exists a condition which cor-
responds to, uncinariasis.
Upson County . _ ? cases, ? deaths.
There is said to exist a great deal of ' ' bloat ' ' in this county. Possibly this ' ' bloat ' '
is due, in part at least, to uncinariasis.
Waldo, Alachua County, 1902. . . about 12 cases, death.
STILES (1903b, p. 44).
ALABAMA.
? Locality. . . ? cases, ? deaths.
LYELL, quoted by BLANCHARD, 1888a. Could not be traced.
Middle Alabama, 1902 _ _ 1 case, death.
HARRIS (1902c, p. 776).
Mobile and vicinity 24 cases, death.
The following extracts are made from a letter dated March 3, 1903, from DR. E. D.
BONDURANT, professor of pathology, medical department, University of Alabama:
"Some weeks ago a fellow practitioner told of cases of intense and protracted anemia
he was treating, suggested the possibility of uncinariasb, and asked me to make a
microscopic examination of the fecal discharges. This was done, and I had no
difficulty in promptly identifying the hookworm ova in the feces of every one of his
4 cases. Shortly afterward I came upon 2 cases in my own practice, found the ova in
quantity, and after thymol I found numbers of adult worms. At the city hospital
we have already had several [?3] others, and one physician who has actively taken
up the search in his anemic 'country patients tells me that he has found about 15
cases. There is no doubt that the disease is very common in the country surround-
ing Mobile. * * * Our 'poor whites' are surely widely infected with the
disorder * * * ."
In a letter dated March 13, Dr. E. D. Bondurant says: "I have, since 1 last wrote
you, diagnosed cases from Monroe County, Covington County, and Crenshaw County,
this State, as well as numerous other cases in the district immediately around
Mobile. * * * All of my cases have promptly improved after thymol."
Monroe County, 1903 1 case, death.
Quoted on the authority of a letter dated March 3, 1903, from DR. E. D. BON-
DURANT.
Waldo, Talladega County ? cases, ? deaths.
A trained nurse, Miss Edith Lide, has described to me a family at Waldo whose
symptoms (anemia, heart, emaciation, dirt-eating, etc.) point almost unmistakably
to hookworm disease.
MISSISSIPPI.
One of the American physicians (Dr. Kirby-Srnith) who saw several
cases of uncinariasis in Cuba has recently stated to me that this disease
is undoubtedly present in Mississippi, but its exact nature has not been
recognized. He is convinced that he himself has seen a number of
cases which were confused with malaria.
107
ARKANSAS.
Uncinariasis does not appear to be proved as yet for Arkansas, but
I have been told that it is probably present.
LOUISIANA.
Louisiana, prior to 1821 and 1850 . _ _ 1 ? cases, ? deaths.
[ CHABERT'S (1821a) and DUNCAN'S (1850, St. Mary Parish) accounts of dirt-eating
apply very well to uncinariasis. See STILES (1902b, p. 207) .
New Orleans, 1899 _ .1 case, death.
TEBAULT'S (1899) case. See STILES (1902b, p. 209).
Dirt-eaters are said to be numerous in the Mississippi Delta near Baton Rouge.
TEXAS.
Locality?, 1864 1 case, 1 death.
HERFF'S (1864) case in Mexican woman. See STILES (1902b, p. 208).
Galveston, 1894 1 case, death.
ALLEN J. SMITH'S case, reported by SCHAEFER (1901). See STILES (1902b, p. 208).
Galveston, 1900-1901 . . .1 case, death.
; SCHAEFER' s (1901) case; probably infected in Mexico. See STILES (1902b, p. 211).
Galveston, 1901 8 cases, death.
ALLEN J. SMITH'S cases, reported in part by SCHAEFER (1901). See STILES (1902b,
p. 211) . At least one of these cases was due to Uncinaria americana.
Encinal, La Salle County; Heampstead, Waller County; Lavaca
County, 1898 ? cases, ? deaths.
Upon seeing my description of hookworm disease and the photograph from which
figure 42 was made, MR. CHARLES A. PFENDER, assistant in the Zoological Laboratory,
IT. S. Bureau of Animal Industry, stated to me that he had seen similar conditions
among Mexican children in Encinal, among negroes at Heampstead in Brazos River
bottom, and among the poorer people in the southern portion of Lavaca County,
along the Navidad River.
CENTRAL STATES,
ILLINOIS.
Chicago, 1902 1 case, 1 death.
CAPPS (1902a; 1903a, pp. 28-33) : Patient, G. L., in Cook County Hospital; male; 52
years old; carpenter; American. Infection probably took place at Panama. Earliest
symptoms two years ago, aching pain in upper belly, loss of appetite, and weakness.
No nausea or vomiting. Bowels irregular, loose or constipated. Later, shortness of
breath and dizziness; also palpitation of heart. In hospital fifteen months at New
Orleans; diagnosis, pernicious anemia. September 9, 1902, admitted to Cook County
Hospital; pains in belly, weakness, dyspnea, and palpitation. After sitting or
standing feet would swell. Frequent dizziness and faintness. Occasionally had
developed moderate fever, at which time epigastric pain was worse. Appetite poor.
Constipation. Gradual, moderate emaciation.
"Status presens. Man of medium build; skin of a lemon-yellow color. Fatty
layer fairly well preserved. Sclerotics bluish and muddy. Lips and mucous mem-
branes almost bloodless. Palpable arteries moderately thickened. Pulse of large
volume, soft and compressible; low tension, with a decided water-hammer character.
Lungs negative. Heart dullness extended to the left nipple line, to the upper border
of the third rib above, and to the right edge of the sternum. The impulse was forci-
ble and diffuse. Over the apex was a systolic blow transmitted to the anterior axil-
108
lary line. A louder bruit of a different pitch was audible over the mitral area and
the base. The pulmonic sound was louder than the aortic closure.
" The spleen was not palpable, though its area of dullness was enlarged. The liver
was not felt. T*he epigastric and umbilical regions were tender to pressure. Knee
jerks present but not prompt.
''Temperature 98.6, pulse 90, respiration 20. Urine 1.015; no albumen, no sugar,
and no casts.
11 September 11, blood examination showed hemaglobin 18 per cent; reds, 2,576,000;
whites, 6,600. No stained preparations were made.
" September 15, gastric contents were expressed one hour after a test meal of tea
and toast. No free HC1 present; no lactic acid.
"September 23, blood examination, hemog. 17 per cent; reds, 2,280,000; whites,
6,000.
"October 20, blood examination, hemog. 12.5 per cent; reds, 843,000; hematocrit,
980,000; whites, 4,500; color index, 0.80; volume index, 1.17. The differential count
showed: small mononuclear, 10 per cent; large mononuclear, 11 per cent; polymorph.
neutrophile, 66 per cent; polymorph. eosinophiles, 13 per cent; no rouleaux forma-
tion; no nucleated red cells; poikilocytosis marked; polychromatophilia marked.
''The presence of pronounced eosinophilia in a case of grave anemia made us
strongly suspect the existence of an intestinal parasite, so that the stools were exam-
ined frequently. The earlier specimens of feces were watery from the rectal injections
employed, and were therefore not easily studied. In a formed movement, however,
the ova were found in large numbers. These eggs corre -ponded accurately in dimen-
sions to those of Uncinaria duodenalis, measuring about 56 microns in length and 34
microns in width.
" Subsequently the eggs of Tricocephalus dispar were found in small number by
Dr. J. L. Miller. Charcot-Leyden crystals were present in some preparations, absent
in others. Cover glass smears of feces hardened in alcohol and ether were stained
with hematoxylin and eosin and eosinophilic granulations demonstrated. These
granulations, like the Charcot crystals, were never numerous, as is so often the case
in ankylostomiasis.
" The eggs were successfully cultivated and the larva? brought to mature develop-
ment. These experiments will be described later.
"November 6, examination of the blood gave: hemaglobin 11 per cent; reds,
748,000; hematocrit, 915,000; w r hites, 5,600; color index, 88 per cent; volume index,
122 per cent. Differential count: small mononuclear, 15.8 per cent; large mono-
nuclear, 6.8 per cent; polymorph. neutrophile, 70.2 per cent; eosinophile, 7.6 per
cent; eosinophilic myelocytes, 0.2 percent; mast cells, 0.4 per cent. Poikilocytosis
and polychromatophilia marked. Coagulation time, five minutes.
"Previous to this examination the patient had taken thymol in small doses, and
it is not unlikely that many parasites were swept away and lost in the stools. The
diminished eosinophilia and the small number of eggs found in the stools thereafter
lend support to this assumption.
"History in the hospital Treatment, on the whole, was unsatisfactory, because of
the profound weakness of the patient and the irritable condition of the stomach. A
persistent nausea set in that interfered with stomach feeding and made the adminis-
tration of thymol ineffective and even hazardous. Nutrient and salt enemata were
resorted to, but the vomiting persisted until the patient succumbed, on November 13.
"During his stay in the hospital the most conspicuous symptom was epigastric pain
of a dull nature at first, subsequently colicky. In the last two weeks this pain
became continuous, and was accompanied by a great tenderness over the epigastric
and right hypochondriac regions. The liver mass extended at this time about 2
inches below the ,costal arch, and the tenderness, on pressure, was as great as that
seen in hepatic abscess.
"The bowels, as a rule, were constipated, and required rectal enemata. The tem-
109
perature was usually normal, and ranged between 98.5 and 99.5 F. A tendency to
hemorrhage was nowhere to be seen, except from the intestinal tract. The feces
gave the prussian-blue reaction for iron.
"The examination of the eye grounds was twice carried out under difficulties.
No retinal hemorrhage was apparent.
''The blood findings throughout were of a most suggestive nature; an anemia,
at first of the secondary type, progressing until it corresponded in most respects to a
primary pernicious anemia. The individual corpuscles grew .larger and held an
ever-increasing amount of hemoglobin, the color index rising from 38 to 88 per cent,
and the volume index reaching 122 per cent. The poikilocytosis was sufficiently
outspoken, as well as the polychromatophilia, for a primary anemia. The scarcity
of nucleated red corpuscles and the entire absence of megaloblasts is unusual in
the primary pernicious form, yet some such cases have been reported. What
convinced us that the anemia was not of the usual primary type was the eosinophilia
of 13 per cent, for in the primary disease the eosinophiles are rarely increased. On
the other hand, the Uncinariae and most of the other intestinal parasites are char-
acterized by an increase in the eosinophilic cells.
"Autopsy. The post-mortem examination was made November 13 by Dr. Harris,
resident pathologist of the hospital. His report is as follows:
"Body is that of a fairly well-developed and fairly well-nourished man 162cm.
tall. Post-mortem rigidity and lividity present.
"There is a scar 0.5 cm. long on left arm, some edema of lower extremities.
Paniculus adiposus well preserved and of a light-yellow color.
" Abdominal cavity: Diaphragm reaches to the fifth rib on the right side and to the
sixth rib on the left. Some free straw-colored fluid in peritoneal cavity. Omentum
extends down to the pelvis over the intestines and contains a considerable quantity
of fat.
"Pleural cavities: Some firm fibrous adhesions at right apex. About 1,000 c. c.
straw-colored fluid in right pleural cavity; about 250 c. c. in left. Lungs do not
meet in median line.
"Pericardial cavity: About 500 c. c. of straw-colored fluid in the. pericardial cavity.
This fluid contains a few fibrinous flocculi. The pericardium is thin and surface is
smooth.
"Tongue, pharynx, larynx, not examined. Thymus absent. Esophagus and
trachea negative.
"Lungs: Left lung smooth externally, marginal emphysema, crepitates through-
out, floats in water, cut surface smooth, pale, and drips fluid. On the diaphragmatic
surface is a caseated nodule 8 mm. in diameter. Right lung with the exception of
the caseous nodule corresponds to the description of the left. Both lungs are quite
free of pigment and weigh 2,870 grams. Peribronchial lymph glands are negative
except for anthracosis.
"Heart: Cavities are quite empty, left ventricle contracted; aortic and pulmonary
semilunar valves are competent, read by water test. Some fibrous thickening at the
base of the aortic valves. One of the valves has small fenestration 3 mm. long.
Pulmonary valves show no change. The mitral orifice admits three fingers, and the
valve shows a small amount of fibrous thickening, especially near the free borders.
The tricuspid orifice admits five fingers; the valves show no changes. The left
ventricle has an aberrant corda tendina extending from the septum to the left wall.
Ventricular wall measures 16 mm. ; right ventricular wall measures 5 mm. Heart
muscle is firm and very yellow, but not mottled. Heart weight, 300 grams. There is
a slight increase of the subepicardial fat. There are a few atheromatous patches in
the ascending aorta.
"Spleen: About one-half larger than normal; capsule is smooth, parenchyma is
quite firm; malphigian bodies prominent; there is an evident increase of connective
tissue. The organ w r eighs 225 grams.
110
"Kidneys: Eight weighs 175 grams. Section pale, cortical markings not well
seen; relation between cortex and medulla is normal; capsule strips readily; pelvis
is normal. Left kidney weighs 135 grams. Answers to the description of its fellow.
"Ureters, bladder, testicles, and adrenals present no abnormal appearances.
' ' Liver : Extends 4 cm . below costal arch ; capsule smooth and glistening presents
yellowish mottled appearance. Cut surface mottled yellow and red, lobules well
seen. Liver cuts with decreased resistance. Weighs 1,600 grams. Bile ducts pat-
ent, bile dark brown, no concretions. Pancreas shows no changes.
"Stomach: Of normal size, externally is normal; mucosa is covered with much
grayish-yellow mucus; no parasites.
" Small intestines: External appearance normal. Intestines contain a very large
amount of very tenacious mucus. In the duodenum was found one hook worm.
One hundred and fifty w r ere found in the jejunum and upper part of ileum, being
most numerous in the upper and middle jejunum. None found in last 18 inches of
ileum. They were very adherent, and were in the proportion of about four females
to one male. At point of attachment of some of the parasites was found a small
ecchymotic spot, and scattered along the rest of the mucosa a few other ecchymotic
spots were seen possibly points of previous attachment. The mucus in places was
blood-stained. Mesenteric glands were enlarged and of a pinkish color. Appendix
lies in false pelvis to the outside of psoas muscle and behind cecuin bound down
by fibrous adhesions and curled at its tip.
' ' Spinal cord shows no microscopic changes.
"Bone marrow removed from femur. Marrow is yellow and very fatty. At two
points it had a reddish color, but was even here practically all fat.
" Anatomic diagnosis: I. Uncinaria duodenalis of small intestine. 2. Ecchymosisof
intestinal mucosa, and hemorrhage into intestinal lumen. 3. General anemia and
edema of dependent portions of body. 4. Bilateral hydrothorax. 5. Hydroperi-
cardium. 6. Edema of lungs and caseous tuberculosis of lower left lobe. 7. Slight
atheroma of aorta. 8. Fatty degeneration of heart and liver. 9. Aberrant corda
tendina. 10. Passive congestion and fatty degeneration of liver. 11. Chronic inter-
stitial splenitis."
WESTEKN STATES.
MISSOURI.
St. Louis, 1893 1 case, death.
BLICKHAHN'S (1893a) case; probably imported from Germany and caused by Agchy-
lostoma duodenale. See STILES (1902b, p. 208).
St. Louis, 1901_. ..1 case, death.
DYER'S (1901) case. See STILES (1902b, p. 213).
CALIFORNIA.
San Francisco, 1902 ..'. 2 cases, death.
Letters from Drs. G. H. EVANS and MARY HALTON, 1902: Two soldiers who returned
from the Philippines. Through the kindness of the observers I was able to exam-
ine specimens from one of these cases, and to convince myself that they belonged
to the American species. The previous history of the patient was not obtained.
San Francisco, 1903 2 cases, death.
BROWN (1903, p. 107): Three patients infected with Strong yloides; 2 of these (natives
of Porto Rico) were also infected with Uncinaria.
? Locality . .. . .3 cases, death.
L. MIFFITT'S (cases cited by CAPPS, 1903a). Two cases from Mexico, one from the
Philippines. Diagnosis by ova.
Ill
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For the general literature on uncinariasis the reader is referred to
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INDEX TO ZOOLOGICAL NAMES.
Page.
Agchylostoma 3, 11, 13, 14, 15, 16, 21, 36
caninum 17, 103
duodenale 3, 7, 9, 13, 15, 17, 18, 19, 21, 22, 23, 24, 26,
27, 29, 31, 32,33, 34, 50, 52, 56, 59, 60, 61, 63, 89, 99, 110, 111, 112, 115
Amoeba coli . 116
Anchilostoma 15
duodenale 21
A nchylostamum 15, 92
duodenale . 21, 114
Anchylostoma 15, 16, 72, 92
duodenale 21
Ancylostoma 15
duodenal? 21
Ancylostomum 15
duodenale 21, 116
duodenate 21
Ankylostoma 15, 115
' duodenale 21, 114
Ankylostomum 1 5, 114
duodenale 116
Ascaris criniformis 12, 15
lumbricoides . 12, 37, 38, 75, 82, 85
B'dharzia 77
Bunostomum 14
phlebotomum 17
Dicrocoelium lanceatum 8, 84
Dochmius 15
anchylostomum 21
duodenalis 21
Docmius 15
duodenalis 21
Dohmius * 15
Doomius 15
Fasdola hepatica 8, 84
Hxmonchus contortus 14, 17, 75
Ostertagi 75
Hymenolepis 42
nana 8,41,42,85
Meles taxus 12
Metastrongylus 14
Monodonta 15
117
118 INDEX TO ZOOLOGICAL NAMES.
Page.
Monodontus 14, 15, 19
semicircularis 15
(Esophagostoma dentatum 7, 13
Ollulanus 4
Oxyuris vermicularis 8, 57, 82, 85
Rhabditw 24
Rhizoglyphus parasiticus 60
Schistosoma 77
hfemalobium 8, 84
ticlerostoma 14
duodenale 21
Sclerostomintti 14
Strongylidse 3, 1 2, 13, 14, 24
Strongylinse 3, 14, 15
Strongyloides 110, 111
intestinalis 116
stercoralis 8, 60, 69, 82
Strongylus 13, 14
contortus 14
duodenalis 21
quadridentatus 21'
Syngamus 14
Tsenia saginata 8, 84
soliuni 8, 84
Trichuris affinis 8, 82
depressiuscula 116
trichiura 8, 37, 41, 82, 85
Trichocephalus dispar 85
Tricocephalus dispar 108
Unciaria 15
Uncinaria 3, 11, 13, 14, 15, 16, 19, 21, 32, 34, 37, 41, 49, 54, 57, 85, 93, 100, 103, 110
americana 3, 9, 13, 17, 18, 19, 20, 33, 34, 35, 38, 39, 40, 41, 42, 43, 48, 58,
65, 75, 85, 88, 91, 96, 97, 98, 99, 100, 101, 102, 103, 105, 107, 111, 113, 115
canina - 14, 17
cernua 17, 34
duodenalis 3,14,16,21,24,35,108,110,113,115,116
Lucasi 17,34,48
melis - 15
radiata 17, 34, 75
stenocephala 14, 15, 17, 19, 34
trigonocephala 17, 34, 48, 75
vulpis 15, 19
Uncinariinae
Unicinaria 15
americana 19
Vulpes lagopus 17
vulpes 12
INDEX TO AUTHORITIES CITED.
Page.
Allyn, Herman B 33, 99, 11 1
Anderson, John F , 2, 100
Arslan, Ervant 68, 111
Ashford, Bailey K 33,34,58,70,98,111
Bailhache, Preston H 98
Barringer, Dr 101
Bason, 31
Behrend,M 33,99,111
Bentley, Charles A 59,60,61,62,63,64,111
Blanchard, Kaphael 101, 102, 106, 111
Blickhahn, Walter L .' 32,110,111
Blumer, George 98, 111
Bondurant, E. D 106
Boring, J. W 44
Boston, L. Napoleon 33
Brown, M. S : . 42, 104
Brown, Philip King 69, 110, 111
Burt,A.Moody 42,48,105
Causey, P. P 38
Capps, Joseph A 91,107,111
Carrington, Charles V 37
Chabert, Jean Louis - 32, 52, 107, 1 1 1
Chevalier, J. Damien 31, 111
Clark, George Archibald 39,113
Clark, M. A 41,66
Clay tor, Thomas A 33, 91 , 99, 100, 1 12
Corbett,J.W . 39
Cotting,J.R 32,52,76,102,112
Cragin,F.W 67,76,112
Dalgetty , A. B 60, 62, 1 12
Dawson, 73
Dawson, Charles F 17
Dawson, John 40
Dazille, Jean Barthelemy 31, 112
De Saussure, Henry W 41 , 102
Dobson, Edwin F. H 80,112
Drewry, F.D ' 38
Dubini, Angelo 13, 31, 92, 112
Duncan, James B 32,52,107,112
Dyer,J.H 33,110,112
Ebers, Professor , 31
Edwards, - - - 31
Eichhorst, Hermann 89, 112
Elliot (of Assam) 62,112
Ely, W. W 98, 112
Evans, G. H 110
119
120 INDEX TO AUTHORITIES CITED.
Page.
Flexner, Simon 2
Francis, Edward 2
Frcelich, Joseph Aloysius 12, 112
Garrison, Philip E 2, 37
Geddings, William H 32, 101
Giles, Surgeon-Major 49, 54, 56, 72, 87, 92
Goeze, Johann August Ephraim 13,112
Gould, A. N 98, 112
Gray, William B '. 33, 100, 112
Green, J. Mercier 41
Greene, Joseph B 98, 113
Gregory (of Kershaw) 39
Guiteras, John [Juan] 34, 69, 105, 113
Hall, E. Lee 99, 113
Halton, Mary 110
Hancock, J.' 76,113
Hardman, Lamartine G 41, 104
Harris, H. F 35, 36, 41, 79, 80, 96, 103, 105, 106, 109, 113
Helms, J. S..... 105
Hemmeter, John C , 99, 113
Herff, F 32, 107, 113
Herrick, A. B 99, 113
Heusinger, - - 32, 101
Hilsman, Parlarmon L 43, 66, 104
H uger, William H 41, 58
Imray, John 52, 67, 76, 113
Izlar, A. L 44
Izlar, R. P 44, 105
Jacoby, Martin 31, 52, 68, 116
Joachim, H 31, 113
Jordan, C. H 32,52,76,111,113
Jordan, David Starr 39, 113
Kauffmann (of Cairo, Egypt) 91
Kirby-Smith 96, 106
Labat, - 31
Le Conte, John ! 32, 52, 75, 102, 114
Lepine,R 89,114
Lethermann, : 32
Leuckart, Rudolf 82,84,114
Lide, Edith 106
Little, Robert Edmonds 32, 39, 114
Looss, Arthur 30, 50, 56, 60, 63, 64, 84, 114
Lucas, Frederick A 17, 39, 48
Lusanna, Felice 68, 1 14
Lute,- - 56,68
Lyell,- 32,102,106
McClintic, Thomas B 2
McHatton, Henry 42, 48
Miffits,L 110
Miller, J. L 108
Mcehlau,F.G 33,98,114
Murray, Arthur L 2
Neuman, 98
Ohlmacher, A. P 69
INDEX TO AUTHORITIES CITED. 121
Page.
Osier, William 51, 99
Parker, Herman B 2
Perroncito, Edoardo 114
Perry, M. L 42
Pfender, Charles A 87,107
Piso, Gulielmus 31, 114
Pitt, Joseph 32,101,115
Plasencia, Leonel 115
Pollard, Thomas 76,100,115
Powell, Thomas 42
Hansom, Brayton H 2, 85, 100, 111
Rosenau, Milton J 1,2
Salmon, Daniel Elmer
Sandwith, F. M 30,31,45,46,49,50,53,
54, 56, 57, 60, 66, 68, 72, 73, 74, 75, 76, 77, 78, 79, 80, 86, 87, 88, 89, 91, 115
Simons, Grange 41
Schaefer, M. Charlotte 22,33,34,107,115
Scheuthauer, Gustav - 31, 115
Schneider, Anton 115
Scott, 66
Sedgwick, William T 2
Seheult,- - 60
Smith, Allen J 20,32,34,107
Smith, Claude A 35,103,115
Staton,LeeW 38
Sternberg, George M 115
Stevenson, Earle C 2, 37, 100
Stiles, Charles Wardell 115
Strong, Richard P 69, 91, 116
Stuart, Richard H 100
Stubbert, James Edward 66
Tebault,C.H. (jr.) 33,107,116
Thayer, William Sydney 69, 83, 98
Theobald, Frederick B . 88
Thiess, Capt. Adolf 39
Thomas, A. P. 84,116
Urie,John F 2
Vaughan, Victor C
Van Durme, Paul 60, 116
Walker, J. L 44, 105
Ward, Samuel B 98,111,116
Walters, M.H 2
Welch, William H 2
Wesbrook, Frank F 2
White, L.N 38
Wilcox, J. D 44,105
Wille, Clarence W 2
Wilson, Robert (jr. ) 40
Wyman, Walter 2,11
Yates,JohnL - 91,116
Zinn,W 31,52,68,116
O
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