Medicine and Disease in History: Hookworm
Hookworm treatment at the Chapel Hill School, Alabama 1923
By Matt Narbutis
Note: Essay 5 in a series, all from Dr. Amanda McVety’s Spring 2019 class on Medicine and Disease in Modern Society
Imagine yourself as being a child. You are trying to live a normal life, but a mysterious organism inside of you regularly manifests both physical and mental problems. In addition to you, almost half of your friends and family suffer similarly, yet for the most part, no one is even talking about it, let alone trying anything to get rid of it. You may end up free from this condition, but most likely it will be present with you until your death. You’re not living in some sort of apocalyptic disease-ridden world, you are one of the millions of Americans that suffered from Hookworm at the turn of the 19th century. Though having Hookworms was rarely fatal, or even significantly impactful on one’s life, the experience of having the parasitic disease in the 1930’s resulted in physical discomfort and social stigmatization, which were treated by archaic medicines and often vague preventative measures.
In the 1930’s Ancylostomiasis or, as it is still commonly known today, Hookworm, was a disease scientists and health practitioners fought and researched with regularity. The disease was known to be an parasitic infection of the body caused by millimeters-long worms. Throughout the first two decades of the twentieth century, some adamant scientists believed Hookworm infections were either caused by the consumption of contaminated meat or passed hereditarily. However, by the 1930’s it was nearly universally accepted that the infection entered the body almost exclusively through skin penetration, with rare cases stemming from ingesting Hookworm contaminated food[1].
In the 1930’s, the known history of the disease was relatively comprehensive. The disease was first documented in 1838 when an Italian physician performed an autopsy on a peasant woman. By the mid 1800’s, the disease had been documented across the world and known cases existed on nearly every continent. Hookworm’s origins in the United States were thought to be in 1902, though the condition had most likely been in the country for centuries before. Around the turn of the century, many Americans considered the disease to be nothing more than a myth. This line of thinking however, was halted in the 1910’s when various health organizations and the federal government recognized Hookworms to be a prevalent parasitic infection within the country. By the 1920s, the disease was thought to have disappeared for the most part from the U.S. as a result of aggressive treatment and public education.[2]
In the United States one group suffered more from the disease than any other: rural Southerners. Hookworm infections were so rampant in the American South that estimates concluded roughly “30 percent of the rural southern population”[3] was afflicted by the disease. Among rural Southerners, those who had frequent interaction with soils and sand, such as farmers and children, were most likely to have the condition.
The physical experience of having Hookworms was a tedious one. Those suffering from the infection experienced anemia, sluggishness, “Delayed pilosity, aches, dizziness, epigastric tenderness, lassitude, insomnia, constipation, irregular menses,
[and]
frigidity.”[4] Despite these symptoms, infections were rarely lethal with the few actual Hookworm caused deaths primarily a result of anemia in children. This gave rise to the notion among many that Hookworms didn’t necessitate treatment, as it was perceived to be an inconvenient condition rather than a possibly life-threatening one.
The social experiences of having Hookworms were similar to the physical ones: they ranged from uncomfortable to debilitating. Those with Hookworms were stigmatized and often seen as impoverished, low-class, and uneducated due to the disease’s prevalence in the rural southern states. The children who suffered from this disease were thought to be “dull, apathetic, unable to concentrate” and in extreme cases “mentally retarded” due to their infections[5]. Those who were afflicted by Hookworms and resided in the South generally had easier social experiences than sufferers in the Northern States, who were even more heavily stigmatized. This notion makes sense give the diseases relatively rare rate of occurrence in the North compared to the South.
Unfortunately, both the treatments given to sufferers and the preventative measures taken were relatively archaic in the 1930’s. Carbon tetrachloride, a sweet-smelling, volatile liquid closely related to chloroform, which had previously been used primarily as an industrial cleaner, was the standard of care in treating Hookworm infections. Though it was effective in treating patients afflicted by the condition, it could be toxic and cause damage to the nervous system, liver, and kidneys in high dosages. Another common treatment was Chenopodium, a flowering plant that was made into a liquid. However, those who received this treatment often experienced lethargy and the dose had to be administered multiple times before it had any positive effect thereby drawing out the side effects[6], thus making Carbon tetrachloride, which only required one dose, the preferred choice. The preventive measures that were recommended to combat the spread of the disease were fairly vague. Among them were “Proper disposal of human excreta” and the recommendation to “implement sanitary measures.”[7]These non-specific recommendations make sense given the fact that Hookworms had the potential to live in nearly any soil or sand, thereby making specific preventive measures nearly impossible.
Public discourse regarding the disease went through a turbulent reform over time. At the turn of the 19th century, a practitioner’s suggestion that a patient had Hookworms often resulted in the patient being offended. This is no surprise given the negative connotations and social stigma the disease carried. However, generous funding from the Rockefeller foundation for education and treatment of the disease resulted in a massive expansion of the discourse and the legitimacy in which people spoke of it. Additionally, through the help of travelling Hookworm educators, who often spoke at schools, the disease was discussed within communities even more.[8]
In the Southern United States, where the disease was the most prevalent, public health officials did not enforce specific health requirements for disease as they lacked the resources to do so. Trying to implement specific guidelines for how cases of the disease would be reported to public health officials and managed by physicians would have been impossible, due to how frequently the condition presented. However, in the Northern cities, such as New York City, public health officials enforced much stricter regulations, due to Hookworm’s lack of prevalence there. Those with Hookworms were to be removed from hospitals unless they were able to be properly isolated and quarantined, and were prohibited from mobilization so that they would not spread the disease. In addition, physicians attending to cases of the disease had to file official reports noting them or else face heavy penalties. These regulations, combined with the prevailing environmental conditions, helped limit the prevalence of Hookworms in the North.[9]
Both the 1930’s understandings of Hookworms scientifically and historically were quite similar to what they are understood to be today. The developments and insights made in that era laid the foundation for the current research on the condition. Presently, it is common knowledge that Hookworms in humans are caused by an infection with the nematode parasites Necator americanus and Ancylostoma duodenale that are transmitted through contact with contaminated soil. The worms subsequently migrate to the lungs where productive coughing sends them into the gastrointestinal tract where they can cause intestinal blood loss and in some cases, anemia. Historically speaking, it is now know that in the decades leading up to the 1910’s when education and treatment began to take place Hookworms were, and most likely had been for decades prior, an epidemic in the American South. It is also accepted as fact that the treatments of the early 20th century did not nearly eradicate Hookworms as previously thought. Though much has changed since the 1930’s, for the nearly 700 million people who suffer from Hookworm today the feelings of physical discomfort and social stigmatization they experience are akin to those experienced by Americans in the 1930’s.[10]
Matt Narbutis is a second year student majoring in History, with a co-major in premedical studies. Outside of class he participates in cell signaling and cancer related research.
Bibliography
“The Life-History Of The Hookworm.” The British Medical Journal Vol.1, no. 2670 (1912): 499-500. http://www.jstor.org/stable/25296276.
“The Prevention and Cure of Hookworm.” Scientific American 120, no. 14 (1919): 334-53. http://www.jstor.org/stable/26039277.
Hotez, Peter J., Simon Brooker, Jeffrey M. Bethony, Maria Elena Bottazzi, Alex Loukas, and Shuhua Xiao. “Hookworm infection.” New England Journal of Medicine 351, no. 8 (2004): 799-807.
New York (N.Y.). Department of Health. “Provisions of the Sanitary Code of the City of New York and Regulations Relative to Reportable Diseases and Conditions and Control of Communicable Diseases.” (1940): 13-42.
Nicholls, Lucius, and G. G. Hampton. “Treatment Of Human Hookworm Infection With Carbon Tetrachloride.” The British Medical Journal 2, no. 3209 (1922): 8-11. http://www.jstor.org/stable/20420412.
Power, Helen J(Jun 2001) History of Hookworm. In: eLS. John Wiley & Sons Ltd, Chichester. http://www.els.net
[doi: 10.1038/npg.els.0003582]
Smillie, W. G., and Cassie R. Spencer. “Mental retardation in school children infested with hookworms.” Journal of Educational Psychology 17, no. 5 (1926): 314.
Stiles, C. W. “Decrease of Hookworm Disease in the United States.” Public Health Reports (1896-1970) 45, no. 31 (1930): 1763-781.
Ch. Wardell Stiles. “Some Practical Considerations in Regard to Control of Hookworm Disease in the United States under Present Conditions.” The Journal of Parasitology 18, no. 3 (1932): 169-72.
“The Rockefeller Foundation.” The British Medical Journal 2, no. 3493
(1927): 1154-155. http://www.jstor.org/stable/25327296.
[1]Ch. Wardell Stiles. “Some Practical Considerations in Regard to Control of Hookworm Disease in the United States under Present Conditions.” The Journal of Parasitology 18, no. 3 (1932): 80.
[2] Stiles, C. W. “Decrease of Hookworm Disease in the United States.” Public Health Reports (1896-1970) 45, no. 31 (1930): 1763-781. doi:10.2307/4579737; “The Life-History Of The Hookworm.” The British Medical Journal Vol.1, no. 2670 (1912): 499-500; Stiles, CH (1932): “Some Practical Considerations in Regard to Control of Hookworm Disease in the United States under Present Conditions.”
[3]Stiles, C. W. “Decrease of Hookworm Disease in the United States.” Public Health Reports (1896-1970) 45, no. 31 (1930): 1763.
[4] Stiles, C. W. (1930): “Decrease of Hookworm Disease in the United States,” 1770.
[5]Smillie, W. G., and Cassie R. Spencer. “Mental retardation in school children infested with hookworms.” Journal of Educational Psychology 17, no. 5 (1926): 314.
[6]Nicholls, Lucius, and G. G. Hampton. “Treatment Of Human Hookworm Infection With Carbon Tetrachloride.” The British Medical Journal 2, no. 3209 (1922): 8-9.
[7]“The Prevention and Cure of Hookworm.” Scientific American 120, no. 14 (1919): 334.
[8] “The Rockefeller Foundation.” The British Medical Journal 2, no. 3493 (1927): 1154.
[9]New York (N.Y.). Department of Health. “Provisions of the Sanitary Code of the City of New York and Regulations Relative to Reportable Diseases and Conditions and Control of Communicable Diseases.” (1940): 28.
[10] Hotez, Peter J., Simon Brooker, Jeffrey M. Bethony, Maria Elena Bottazzi, Alex Loukas, and Shuhua Xiao. “Hookworm infection.” New England Journal of Medicine 351, no. 8 (2004): 799-807; Power, Helen J(Jun 2001) History of Hookworm. In: eLS. John Wiley & Sons Ltd, Chichester.