4i 
in the city. In the Santa Casa, typical examples of the disease are 
nearly always to be seen. The stunted, vacant-looking, bloated, 
anaemic child with a protuberant abdomen is a common sight. Severe 
anaemia and slight oedema are frequent symptoms in adults. 
The general public do not appear to understand the dangers 
arising from infection with this nematode. All of our severe cases 
of malaria exhibited considerable intoxication due to this cause, which 
materially retarded convalescence. We have not to wait until 
symptoms are pronounced to realise how seriously the health of the 
people is influenced by harbouring ankylostomes. Both children and 
adults exhibit the lassitude, disinclination to work, the inability to 
continue strenuous exercise for long periods, the susceptibility to 
gastro-intestinal disturbances, the lowered resistance to disease and 
proneness to manifest severe, and sometimes grave, complications 
when attacked by mild diseases ; all of which are the result of infection 
with Necator americanus. 
This disease should be feared, because of the danger of neglect of 
treatment until the symptoms have become pronounced, or, more 
probably, because the constitution of the individual has been so 
weakened and undermined that he can fall an easy victim to any of 
the diseases prevailing in the State. 
Malaria, tuberculosis, dysentery and other diseases are seen in 
particularly severe forms in patients evidencing the toxic symptoms 
caused by the worm. 
The habits of the people are responsible for the spread and general 
infection of the soil by this parasite. Public latrines in Manaos are 
absent ; and therefore vacant lots or side streets are used for the 
committing of nuisances. In the suburbs there exists no system of 
drainage ; only a few of the houses possess dry earth closets or privies 
The natural functions must be performed ; and therefore the ground 
in the neighbourhood of the habitations is soiled by the evacuations 
of the residents of the locality. The native usually chooses the belt 
of undergrowth at the edge of his clearing, but often in wet weather 
the earth immediately around or even inside the hut will be 
contaminated by the occupants. 
The vicinity of the washing-pools, the undergrowth along the 
footpaths commonly used by the people, the banks of the igarapes 
and ravines are all contaminated by excreta. 
