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.| B |.g iggjlg |S -^ Tfi -^ iC O to 10 to to to to to ;ggg gog t> (N-^tO GOlC T} 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 BIBLIOGRAPHY. For the general literature on uncinariasis the reader is referred to the Index-Catalogue of the Surgeon-General's Library, and also to the Index-Catalogue of Medical and Veterinary Zoology now being issued by the United States Bureau of Animal Industry. The following list, which has kindly been prepared for me from my manuscript by Mr. B. H. Ransom, comprises only those articles which are cited in the present paper. [W% Library, United States Department of Agricul- ture; W m , Surgeon-General's Library, United States Army, Washing- ton, D. C.I ALLYN, HERMAN B. ; & BEHREND, M. 1901. Ankylostomiasis in the United States. Report of a case