differs from the old world species in two main features; the eggs are larger and instead of the recurved hook-like teeth, the American species has semilunar plates.

LIFE HISTORY OF UNCINARIA.

The life career of uncinaria is a very checkered one. The eggs, which are ellipsoid in shape and measure in the old world species 52 by 32 micro m. m. and in the American species 72 by 40 micro m. m., are protected by a thin shell and are laid in the intestinal tract by the female worms and then discharged in the feces. They do not develop in the intestine, but must pass out of the body. After escaping in the feces the process of segmentation which begins in utero continues, and each egg develops an embryo, the time required varying according to temperature, moisture and position of feces. The embryo lives in water or moist ground. In its evolution, the worm during its larval stage casts its skin off four times and undergoes five changes in its structure before it reaches the adult stage. It is when the worm is in its larval stage that man becomes infected with it. They are swallowed in ordinary water or in contaminated food. Dirt eaters and persons handling dirt are particularly liable to infection. Loos (1898) has demonstrated that one may get infected with the hook worm through the skin, and Bently (1892) advanced the view that the cutaneous affection known as "ground itch" or "pani-ghae," prevalent among coolies, is due to the entrance subcutaneously of the hook worm larva.

PATHOLOGICAL ANATOMY.

The many autopsies made upon those who died from uncinariasis as the primary cause have furnished the following data: The muscles are flabby and pale. Panniculus adiposus as well as the fat of the mesentery, heart and mediastinum is not only preserved, but rather increased. General anasarca, ascites, hydrothroax, hydropericarditis, edema of meninges and lungs have been noticed quite frequently. Anemia of all organs and especially that of brain, lungs, gastric and intestinal mucosa is invariably present. The heart in the majority of cases is dilated or hypertrophied. Liver and spleen are more or less atrophied, and in some cases have undergone amyloid degeneration. In the case of Capps the spleen and liver were found greatly enlarged. The stomach has been found in a great many cases dilated, and Roth

found in one case gastritis with hemorrhagic erosions. The intestines contain a large amount of tenacious, bile-colored mucus. In the duodenum and jejunum are to be noticed many ecchymotic spots. The worms numbering in certain cases several thousand, are found attached to the mucosa of the duodenum and jejunum and are as a rule detached with difficulty. They are never found in the lower segments of the intestine. The female exceeds the male in numbers. The mesenteric glands are found quite often enlarged. The marrow of the large bones is yellow and fatty, and that of the small bones a pale red.

The complications so far observed are pulmonary tuberculosis, pneumonia, pleurisy, malaria, putrid bronchitis, nephritis, mitral stenosis, etc.

SYMPTOMS.

The symptoms vary according to the number of parasites and duration of infection, and can be divided into those arising from the gastro-intestinal tract and those resulting from the anemia. A feeling of heaviness in the region of the stomach, periodic or continuous, and attacks of colicky pains in the abdomen. are the principal complaints for which the patient seeks relief. Nausea, heartburn and vomiting are quite frequent. Weakness and debility which increases from day to day, exhaustion on the least exertion, paleness of face and of all visible mucous membranes are the forerunners of the oncoming anemia, which sooner or later develops into a pernicious type. The skin becomes markedly pale, and assumes a dirty yellow color, it is flabby, dry, cold. Even in negroes the skin becomes pale. The sclerotics are unusually bright, the lips are deathly pale and there is scarely a line of demarkation between skin and mucous membrane. Ringing in the ears, dizziness, vertigo and palpitation present the circulatory symptoms. Shortness of breath and fainting spells are brought on by the slightest exertion. The pulse, at first normal, becomes soon accelerated, intermittent and sometimes thread-like. The pulsation of the carotids is very marked, and a systolic blowing murmur can be heard. The second heart sound is accentuated, and sometimes to such a degree that it can be heard at a few feet distance from the patient. Respiration is frequent and shallow. It is remarkable that hemorrhage from the intestine or stomach has not been noticed. Several investigators have found blue spots on the tongue, and Gurgle is so enthusiastic about this sign that he thinks it pathognomonic.

The examination of the blood presents several points of interest. The red blood corpuscles are markedly pale, and their number diminishes to as low a figure as 850,000 (Stahl); hemoglobin is very low. Eosinophiles are found markedly increased.

DIAGNOSIS.

The clinical symptoms by themselves can never be conclusive but may arouse suspicion, especially when the occupation of the patient is suggestive-workers in dirt and clay, brick yards, tunnels, mines, canals, soldiers, travelers, etc. Anemia of a high grade ought always to indicate an examination of the feces. The presence of eosinophilia is indeed characteristic and pathognomic, since its existence precludes pernicious anemia. One should look for blue spots on the tongue. The presence in the feces of Charcot-Leyden crystals points in the direction of helminthiasis. But the most positive diagnostic point is the presence of the ova of uncinaria in the feces.

PROGNOSIS.

Spontaneous cures are not known to have occurred. Under treatment, however, prognosis is as a rule favorable. In some cases the patients recover immediately after the expulsion of the parasite. In other cases the convalescence is protracted, especially in cases with marked symptoms of pernicious anemia,

TREATMENT.

There is only one drug that proved to be the worst foe of the uncinaria and that is thymol. The treatment is simple. No preliminary preparations are necessary, and fasting is superfluous. The drug is administered in 30-grain doses at 8 and 10 a. m., and at noon a dose of castor oil or magnesia is given. The stools should be examined at short intervals for ova, and no patient should be discharged as cured unless the eggs were not found after two or three months. Some cases are obstinate and require several repetitions of the treatment. Santonin and male fern have been tried but did not prove satisfactory.

CONCLUSIONS.

The consideration of the data regarding the mode of infection by uncinaria, the fact that all the cases in man reported in the United States, so far some 60 cases, date only from the year 1890, that uncinariasis is a common disease in certain parts of this country in dogs, cattle and sheep, and that according to the opin

ion of such acute observers as Stiles and my friend Harris, of Georgia, the disease has been prevalent in the South for many years, but has been ineffectually treated with large doses of quinine for malarial anemia, point to the following conclusions: Ist. That the disease is more or less widespread, and that it is here to stay. 2nd. That not a few cases of obscure anemia, which many of you and myself can recall, may have been due to uncinariasis. 3rd. That the failure to recognize the exact nature of the disease has been due purely and simply to the fact that we have been either too ignorant or too lazy or too squeamish to undertake the task of examining feces macro and microscopically. 4th. That although to my knowledge no cases have been reported up to the present writing from Colorado, there can be no doubt that in a state whose principal industry is mining, and where thousands of workingmen from all parts of the world are congregated under most unhygienic conditions, the infection must exist somewhere, and it should be sought and exterminated.

In conclusion, let me once more appeal to you to make more frequent examination of feces,** and especially when there is a suspicion of the existence of intestinal parasites. For just as every one would admit that it is nothing less than criminal and downright malpractice not to diagnose a case of Bright's disease on the plea that the urine has not been examined, so it is equally criminal and should be considered malpractice when a man goes to perdition with a tape dangling in his inside, or to let a patient bleed to death through uncinaria, the physician pleading neglect of examination of feces as an extenuating circumstance. Do not be fastidious about the odor of fecal matter. When you have once saved a human life by careful examination of this odoriferous excretion, what you consider now as stench will smell sweet to your nostrils as frankincense.

BIBLIOGRAPHY.

Index catalogue of the Surgeon General's Library. Index catalogue of Medical and Veterinary Surgery. Bibliography to the article on Ankylostoma Duodenale in Thierische Parasiten (1894) by F. Mosler and E. Peiper.

Bibliography to the article Uncinariasis or Ankylostomiasis, by Joseph A. Capps, Jour. Am. Med. Association, Jan. 3rd, 1903. Harris, H. F., Am. Med., July 19, 1902, and November

15, 1902.

Stiles, C. Wardell. The significance of the recent American cases of hook worm disease in man, 18th Annual Report Bureau Animal Industry, Washington (1901), and A New Species of Hook Worm parasitic in Man. Am. Med., May 10, 1902.

Gurgle, N. Signol, para o diagnostico da ankylostomiase, Brazil Medico No. 29, 1892, abstract in J. A. M. A., January 3, 1903.

Evans, Geo. H., J. A. M. A., April 11, 1903.

Baker, Oswald, Brit. M. J., March 28, 1903.

*I shall be very glad to report on specimens of feces sent to me for examination without charge. Feces should be sent in a bottle to keep moist; a small quantity is sufficient.

SUDDEN DEATH.*

By EDWARD C. HILL, M.D.

Medical Analyst and Microscopist; Professor of Chemistry and Toxicology in the Denver and Gross College of Medicine; Author of a Text-Book of Medical Chemistry.

SIGNS OF DEATH: Insensibility; recumbent immobile posture (may be erect if lesion in cervical cord); abolished respiration (shown by mirror held before lips); cessation of pulse and heart beat (no immediate flow of blood from cut vein or small artery—until some hours after death); absence of swelling from ligature of finger (turns red or blue if alive); cadaveric sugillations (patches of lividity in dependent parts-altering situation with changes in position of body if recent; not appearing for some hours if death due to hemorrhage; may appear before death in cholera, uremia or asphyxia); dilated pupils (at moment of death, gradually contracting somewhat; mydriatics and myotics have no effect); lessened intraocular tension (often increased after drowning); glazed cornea and brown hue of sclera and conjunctiva (if lids have remained open); dark spot on outer side of white of eye; falling of lower jaw (mouth may be closed from tetanus, strychnin poisoning or hysteria); relaxed sphincters; loss of muscular contractility (after some hours; limb may be drawn up after death in cholera); subnormal temperature (rapid

*For classification and material the writer is indebted chiefly to Bronardel's classic work on "Death and Sudden Death."'