region. There can be no reasonable doubt that what is true as regards the States named likewise holds good for the entire South. Since my first case was reported 13 other instances of the disease have been seen-11 originating in this State, and 1 each in Florida and Alabama; and if all of those encountered who were suffering from anæmia could have been examined there can be no doubt that the number would be many fold greater.

"This communication is written in the hope that Southern physicians will take up this most important matter at once, for in no other serious disease does the victim suffer so long, in no other condition is he for such a period a menace to those about him, and in no other malady of such gravity is the treatment so rapidly and surely successful."

ITINERARY OF TRIP THROUGH THE SOUTHERN ATLANTIC STATES.

DISTRICT OF COLUMBIA.

In September, 1902, with the aid of three assistants (Messrs. P. E. Garrison, B. H. Ransom, and E. C. Stevenson) I began a systematic study of animal parasites among the patients of Government Hospital for the Insane, District of Columbia. From September 10 to December 12, 1902, the stools of 500 male" patients were examined microscopically and 15 patients, or 3 per cent, were found to be infected with hookworms. The history has not yet been examined for each case, but probably most of the patients became infected in Cuba, Porto Rico, or the Philippines.

VIRGINIA.

Richmond and State farm.-Starting on my field work, my first stop (September 25) was Richmond, Va. Through the courtesy and cooperation of D.. Charles V. Carrington I was able to examine at the State penitentiary and the State farm nearly 1,200 convicts. The prisoners filed past Dr. Carrington and myself in single file, and we selected those who appeared anemic or debilitated. Those selected were sent to the hospital and kept there until specimens of feces were obtained. In microscopic examination of 6 white male convicts no case of uncinariasis was found. The only zooparasitic case noticed was an exceedingly heavy infection with whipworms (Trichuris trichiura) in a man about 70 years old.

In 22 male negroes the examination was likewise negative so far as Uncinaria was concerned, but one case of infection of eelworms (Ascaris lumbricoides) was found. In several of the convicts starch digestion or meat digestion was poor, but in most instances the debilitated condition was due to tuberculosis or other diseases.

At the almshouse in Richmond 1 white female 28 years of age gave negative results; a weak-minded girl of 7 years showed a heavy infection with whip worms (Trichuris trichiura). In two negroes (1 male, 28 years; 1 female, 30 years) the examination was negative.

a In 350 female patients examined to March 1, 1903, only one case of hookworm infection has been found.

It proved to be so difficult to obtain specimens of feces from the brickyards that no microscopic examinations were made. No clew was obtained to any disease among the workers which could be interpreted as probable uncinariasis.

Besides Dr. Carrington, I am indebted to Dr. Staton also for cooperation in my work at Richmond.

NORTH CAROLINA.

Virgilina Copper Mine district, southern Virginia and northern North Carolina.--Proceeding to the Virgilina copper mine district I found it very difficult at first to obtain specimens for examination. At one mine 1 white male and 3 negro males were examined; all were negative except 1 negro 22 years old, who showed infection with Ascaris lumbricoides. At this mine defecation under ground is prohibited; it occurs in the surrounding woods, at any place within a radius of about 50 meters from the shaft.

At a second mine three specimens of feces were taken at random from the woods; eggs of Uncinaria americana were found in one specimen, and ova of Ascaris lumbricoides in a second. The patients could not be traced. Specimens were then obtained from 4 white and 18 negro miners, the feces being taken without reference to the physical condition of the men. Of these 22 men, 1 negro 25 years old showed a light infection with Uncinaria americana, and inquiry developed the fact that he "had not been well for some time." His chief complaint had been "diarrhea." In two other cases, a white man 41 years old and a negro 34 years old, eggs of the eelworm (Ascaris lumbricoides) were found. At this mine defecation under ground is prohibited, and a box privy is located within about 50 meters of the shaft. The men prefer, however, to defecate in the surrounding woods.

I am indebted to Drs. F. D. Drewry and P. P. Causey, and to Mr. L. N. White, manager of the Person Consolidated Copper and Gold Mines Company at Durgy, N. C., for their kind cooperation in connection with my work in Virgilina and vicinity.

Cumnock Coal Mines, Chatham County.-The miners at this place were so suspicious regarding my work that it was almost impossible to obtain specimens for examination. In fact only two specimens could be obtained from about 40 men. One of these, a white miner, 52 years of age, and in rather anemic condition, showed infection with Uncinaria americana. The other, a white engineer, 34 years old, gave negative results.

Sanford, Moore County.-Specimens from 4 whites (2 males, and 2 females), obtained by 2 of the local physicians, were examined with negative results.

SOUTH CAROLINA.

Camden, Camden County.-Unexpectedly delayed at Camden, I visited the brickyards with Dr. J. W. Corbett. Of 7 specimens of feces picked up at random from the ground, probably most if not all from negroes, 1 was found infected with Uncinaria americana. One white laborer also showed infection with the same parasite.

Haile Goldmine, Lancaster County.-Through the kindness of Captain Thiess, the superintendent of the mines, and Dr. Gregory, the local physician, I was able to examine specimens from 5 white men and 5 negroes connected with the mine. All of these examinations were negative.

Upon leaving Richmond I happened to recall the observation made by Lucas (in Jordan & Clark, 1898, p. 70) in connection with uncinariasis of the seal pups of Alaska, namely, that the infected animals were almost invariably found on the sand rookeries; I also recalled that I had observed severe outbreaks of uncinariasis in sheep and goats on more or less sandy pastures, and further that a severe outbreak of the same disease among dogs had once been reported to me as occurring in a sandy yard. Not recalling at the time any similar observation for uncinariasis in man, I determined to test the subject at the first opportunity, and from Richmond to Haile Goldmine I had diligently inquired of every physician I met, whether he found more anemia on sand, clay, or rock soil. Most physicians replied that they had paid no attention to the subject; one physician stated that he thought anemia was more common in sandy than in clay localities.

Through Captain Thiess I learned that the land near the mines was chiefly a granite sand. With Dr. Gregory, I drove about 4 miles into the sandy district in Lancaster County and found a family of 11 members, one of whom was an alleged "dirt-eater." The instant I saw these 11 persons I recalled Little's (1845) description of the dirteaters of Florida. (See Stiles, 1902b, p. 208.) A physical examination made it probable that we had before us 11 cases of uncinariasis, and a specimen of feces from one of the children gave the positive diagnosis of infection with Uncinaria americana. There were hundreds of eggs present.

Inquiring for the largest plantation of this sand district, I was directed to a place in Kershaw County, about 6 miles from Kershaw, and through the kindness of Dr. Twitty and the owner of the plantation, I was able to make the desired examinations.

There are about 60 white "hands" on this farm. Going to a field I found about 20 at work. These 20 persons, men, women, and children, corresponded in more or less detail to the description of the so-called dirt-eaters and resin-chewers. A physical examination

showed that they also corresponded to cases of uncinariasis. A family of 10 members was selected and examined carefully. Specimens of feces from 4 of them were examined microscopically and found to contain hundreds of eggs of Uncinaria americana. The owner of the plantation informed me that it would be a waste of my time to examine the remaining 40 "hands," as they were in exactly the same condition as the 20 already examined.

Driving to a neighboring farmhouse, I found a family of 5 members, 3 of whom presented such severe and typical symptoms that I had no hesitation in diagnosing them as due to uncinariasis.

Kershaw County. While driving back to Kershaw, I passed a country schoolhouse. The children, about twenty-five or thirty in number, were at play during recess, and a mere glance at them was sufficient to show that 30 to 40 per cent presented the same general appearance as the children on the neighboring plantation.

At Kershaw several extreme cases were met on the street. The persons in question had come in from the country. One farmer, living about 9 miles away from Kershaw, had with him two of his children. He stated that his entire family, 10 in number, had suffered or were suffering in the same way as these two boys. Physical examination made uncinariasis probable, and the microscopic examination of the feces showed heavy infections with Uncinaria americana.

Inquiry among the local physicians and the more intelligent laity elicited the information that the cases that I had seen represented conditions which were usually attributed to "dirt-eating," "resinchewing," "heart disease," "bloat," "amenorrhea," "anemia due to malaria" (mosquitoes were noticeable chiefly by their absence), "general debility," "poor nourishment," etc. I was further assured that these conditions were general throughout this region, and were not, or only slightly, amenable to treatment.

Taking these cases together, some forty or fifty in all, which I examined carefully within three days, we have one common symptom, namely, anemia; nearly all other symptoms noticed could be reduced to sequelæ of anemia; further, in every case examined microscopically, exceedingly heavy infections with Uncinaria americana were found. Under these conditions, and because the general clinical history corresponded so well with uncinariasis, I have not the slightest hesitation in grouping the cases observed as due to Uncinaria americana.

Charleston, Charleston County.-Through the kindness of Drs. John Dawson and Robert Wilson, jr., I was able to meet the students of the Charleston Medical College. Explaining the object of my trip, I asked for volunteers to submit to microscopic examination. Sixteen of the students and 1 member of the faculty immediately volunteered. Of these 17 men (all white, of course), 4 were found infected with Uncinaria americana and 1 showed a heavy infection with

Hymenolepis nana. The cases of uncinariasis came from the sand districts--namely, Barnwell County; Florence, Saint John County; a sea-coast island near Charleston, and Edisto Island, Charleston County. Through the courtesy of Dr. Huger and the ladies in charge of the Charleston Orphan Asylum, I was able to examine 230 white children, both boys and girls. I picked out 20 for closer examination, because of the anemic condition, or stunted growth, etc. Of the fecal specimens obtained, 15 showed infection with Uncinaria americana. All of the children came from sandy districts of the State-namely, Summerville, Dorchester County; Berkeley County; Adams Run, Colleton County; Plum Island, Charleston County, and McClellanville, Charleston County. One additional case failed to show eggs in the feces, but the clinical history during early childhood seemed typical for uncinariasis (see p. 58, case of L. B.). Of the 4 remaining cases (2 from Charleston (city) and 2 from Edgeville), 1 Charleston boy 114 years old and 1 Edgeville boy 11 years old showed infection with whip worms (Trichuris trichiura).

Besides the Charleston physicians mentioned above, I am indebted to Dr. Grange Simons, president of the State board of health; Dr. J. Mercier Green, city health officer, and several other gentlemen, for their kind cooperation in my work. Dr. De Saussure stated to me that he had found the eggs of Uncinaria in the stools of several patients.

GEORGIA.

Atlanta, Fulton County.-Learning incidentally that Drs. Claude A. Smith and H. F. Harris were continuing their studies on uncinariasis in Atlanta, I left the city without seeing any cases personally. No reason was apparent which made it necessary to confirm their work for this locality, and, furthermore, the territory belonged to them as local men who were carrying on their investigations at their own

expense.

In connection with northern Georgia it may, however, be stated that according to Dr. Lamartine G. Hardman, a member of the Georgia legislature, a condition exists in Jackson County, Ga., which corresponds to what I found in Kershaw and Lancaster counties, S. C.

Macon, Bibb County.-Through the kindness of the local physicians I was able to examine two white orphan asylums in Macon.

In one of these, Dr. Clark (consulting physician) and I selected from among the 85 children 17 boys and girls for closer examination. The selection was made in the same manner as at Charleston, namely, because of the pale, weak, or otherwise poor condition. Microscopic examination showed 12 cases of infection with Uncinaria americana, 2 cases of infection with Hymenolepis nana, and 3 negative cases. The uncinariasis cases came from sandy districts, namely: Americus, Sumter County, 1; Buena Vista, Marion County, 2; Thomasville, Thomas