Hookworm disease

North Carolina State library
Raleigh Tj^Jm^

HOOKWORM DISEASE
By-
John A. Ferrell, M.D,

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in 2010 with funding from
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HOOKWORM DISEASE

JOHN A. FERRELL, M,D.

Assistant Secretary North Carolina State Board of Health for the Eradication
of Hookworm Disease

ISSUED BY

NORTH CAROLINA STATE BOARD OF HEALTH
RALEIGH, N. C.

REVISAL No. 2

EDWARDS & BROUGHTON PRINTING CO., RALEIGH, N. 0.

Hookworm Disease

John A. Ferrell, M.D.,
Assistant Secretary for the Eradication of Hookworm Disease.

HISTORY AND GEOGRAPHICAL DISTRIBUTION OF
HOOKWORM DISEASE.

First Knowledge of the Disease. — Evidence tends to show that
hookworm disease has existed from time immemorial. Even in the days
of the Egyptian Empire the existence of such an anaemia-producing dis-
ease had been spoken of, though its cause was not understood. Not
until 1838 was the hookworm mentioned in medicine. Then it was seen
by Dr. Angelo Dubini, an Italian, who, in performing an autopsy, found
a small white worm with its head buried in the mucous membrane of
the small intestine. Beyond this, little advancement was made until
1877, when the eggs of the worm were discovered in the stools of an-
aemic, pale-blooded patients, by Grassi, another Italian physician, and
the parasites and anaemia were associated.

Recognized as a Cause of Death. — During the construction of St.
Gothard Tunnel, which was undertaken in 1872, many of the tunnel
diggers became sick and died. Dr. Colomiatti found in the intestine of
a man who died with the tunnel sickness more than fifteen hundred
hookworms. Since that time the parasite has been recognized as the
cause of anaemia, and is now termed the hookworm.

Found Prevalent in Old World. — In the Eastern Hemisphere the
disease was studied and found prevalent in regions where its existence
is favored by climatic conditions. It is now known to belt the globe in
a zone extending from 30° south latitude to 36° north latitude.

New Type Found in America.— Only in recent years has the presence
of hookworm disease in America been known. The worm, here, though
exercising the same action on man as those found in the Old World,
differs distinctly from them in many anatomical details. Since it is
with the hookworm of America, known as the New World hookworm,
that we are to deal, except in very rare instances, the worm described
later will be of the American type.

Climatic and Geographical Conditions Determine Its Distribu-
tion.— The distribution of hookworm disease is dependent upon cli-
matic, geographical and sanitary conditions. A combined condition of
warmth and moisture, with the presence of oxygen, is necessary for
the propagation. Thus, in the tropical and subtropical zones, where
the fall of rain is sufficient to keep the earth moist, we have an ideal
surrounding for hookworm disease.

Moreover, the infecting hookworm larva thrives best where the soil is
saady and porous, where it can easily bury itself deep enough in the
soil to be beyond the drying action of the sun.

Infected People Necessary for Spread of Disease. — All the favor-
able conditions for the disease may prevail in a given locality and yet
no hookworm disease will exist, unless the eggs of the parasite have
been deposited there with the feces of some infected person and allowed
to develop. Hence, in cities, where sewerage systems are used, or the
night soil collected and hauled away, regardless of climatic conditions,
we do not find the disease.

Rural Sections Favorable to Its Spread. — Elsewhere, on the con-
trary, where open privies and, far too often, no privies at all, are used,
millions upon millions of eggs are scattered over the earth, and develop
into minute, infecting worms ready to attack and victimize any accessi-
ble member of the human family.

In the Southern States all the factors necessary for the propagation
of the disease are found. We have the warmth, moisture, oxygen, and
infected people, who pollute the soil. North of the Ohio and Potomac
rivers the climate is too cold and, in the arid West, too dry to favor
the disease. In these sections, therefore, the' disease is rare.

Hookworm Disease Affects Animals. — Domestic and wild animals
suffer from hookworm disease. Cows, dogs, cats, and foxes, and many
other animals in certain localities, have been known to sicken and die
in large numbers from hookworm disease. For man it is indeed fortu-
nate that the hookworms found in such animals do not molest him.
The hookworm which infests man belongs to a type separate and dis-
tinct from those found in animals.

These facts considered, let us now direct our attention to the hook-
worm as a parasite and a disease producing factor.

THE HOOKWORM: ITS LIFE CYCLE.

Hookworm Eggs. — The hookworm (see Figs. 1 and 2) germinates
from an egg. This egg (Fig. 3), with myriads of others, passes with
the excreta from the bowels of an infected person. A lack of oxygen
in the human intestine prevents its hatching until it has passed from
the body.

( )

Figure 1. A male hookworm, natural size.

Figure 2. A female hookworm, natural size. (P. H. & M. H. Service.)

Size of Egg. — The egg is far too small to be seen by the unaided eye.
It must be magnified a hundred times to be recognized. So small is it
that in a portion of feces no larger than the head of a small pin two or
three dozen eggs may be found. In shape, size and markings it differs
distinctly from the egg of any other worm. It is oval, rather bluntly
rounded at the ends. The yolk is dark in appearance and is surrounded
by a clear, transparent zone which separates it from the shell.

Figure 3. Development of old world hookworm. A, B. C, D, E, F, G, changes occurring
in egg preparatory to developing of little worm. H, I. J, K, stages of the worm's development
until it emerges from the eggshell. L and M, empty eggshells. Greatly enlarged. (After Per-
incito. Courtesy of C. V. Mosby Pub. Co.)

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Figure 4. This shows a shoe of skin as seen under the microscope. Notice how the young,
hookworms are crawling through the skin. This is the way "ground-itch" or "dew-itch'-
looks. (P. H. & M. H. Service.)

Eggs Hatch in 12 to 24 Hours.— In the open air, with other condi-
tions favorable, the egg requires only one or two days to germinate into
an embryo or tiny larva. This larva bursts forth from its encasing
shell and begins feeding. Rapidly developing in size, it, within a week,
twice sheds its skin, the new skin forming underneath the original one.
The second skin is detached from practically the entire body surface,
but remains about the larva as a protecting sheath.

Requires a Week to Reach Infective Stage. — At this stage of its
development the worm is still too small to be seen with the unaided
eye; in fact, many of them could live in a single drop of water and
yet not be crowded. Reaching this period in its life cycle, it is known
as the encysted larva. As such it takes in no more food, and grows no
more, but possesses remarkable vitality. It will live thus six weeks,
perhaps nine months. This little larva has reached what is known as
the infective stage.

In order to continue life and develop further, it must enter the body
of a human being — its host — and find its way to the intestinal canal,
for only there can adult life be reached.

MODES OF INFECTION.

Contaminated Food or Water May Carry Infection. — Early writers
held that the infecting larva was swallowed with contaminated water or
food. Celery, lettuce, radishes, strawberries or other fruits might carry
the larva, yet one's eyes could not see the tiny enemy. Thus a person
may, unknowingly, swallow it and become infected. The hands of a
child may make mud pies of polluted soil and, without being washed,
carry bread to the child's mouth. At present, infection through the
mouth is regarded as occurring much less frequently than through the
skin.

Skin Infection Very Common. — The common mode of infection is
known to be through the skin.

Figure 5. Experimental Hookworm Infection. Shows confluent vesicle (blister) for ma
tion with slight decrease of swelling. {Photograph furnished by Dr. Claude A. Smith. Courtesy
of C. V. Mosby Pub. Co.)

6

Loose experimentally demonstrated that if water or soil contaminated
with the encysted hookworm larva is brought in contact with the skin
(Fig. 5), the parasite will attach itself and bore its way through the
skin. The old protecting sheath is left behind as the larva enters the skin.

Six Weeks Required to Complete Development. — After about six
weeks the eggs of the adult worm will begin to pass regularly in the
stools of the infected person. Treatment reveals the adult worm, and
on its completion there is no further appearance of eggs in the stools.
Others have since confirmed this work. All noticed that ivhen the larvw
are penetrating the skin, a typical "ground itch" develops. Since many
thousands of cases have been treated, and in all cases with, of course,
some exceptions, a history of "ground itch" is given, which occurred
prior to the beginning of the impaired health of the host, we are con-
vinced that "ground itch" (Fig. 4), "dew poison," or "foot itch," as it
is variously termed, is the initial symptom of hookworm disease.

How the Little Worm Passes From the Skin to the Intestine. —
Entering the skin (Fig. 4), the larva probably directly, or indirectly
through the lymphatic system, reaches the blood current and by it is

V,

Figure 6. This shows two young hookworms in the lungs. The worm on the left is
entering the air tubes. (P. H. & M, H. Service.)

swept through the heart and on to the lungs (Fig. 6). Being too large
to pass through the blood capillaries of the lungs, it bursts out of them
and enters the air spaces. It probably crawls along these until the
trachea or windpipe is reached. This is ascended. In turn this active,
resistant, unseen foe reaches the throat, passes down the esophagus to
the stomach, and ultimately to the small intestine.

Development Completed in Intestine. — Its struggle for existence
may now be rewarded, for it is at its final home and may complete its
development, becoming an adult hookworm. In this transition it twice
sheds its skin, takes much food, and grows remarkably in size.

Size of Adult Hookworm:. — The adult hookworm varies in size from
one-third to two-thirds of an inch in length (see Figs. 1 and 2), and is
about the thickness of a small hairpin or a No. 30 thread.

Color. — It is white, as a rule, but will often appear of a dark, brown-
ish color, due to blood taken into its system.

Figure 7. Selma Ellis, of Columbus county. Photograph made at county dispensary.
Age 16, weight 62J^ pounds; anemic ulcer on leg; ill 8 years. He was unable to go to school
or work; in fact he was unable to sit or stand.

Reason for the Name. — The name hookworm may have originated
from the appearance of the worm. Its head bends back on its neck like
a hook; the teeth of the Old World hookworm closely suggest hooks;
and, in the male, the rays or ribs in the fan-shaped tail resemble hooks.
Hence, there are three excuses offered for the name.

Peculiar Structure of Worm. — The mouth is cup-shaped (Fig. 8).
There is a prominent dorso-medial tooth and two ventro-lateral curved
plates just within the outer margin of the mouth. These enable the
worm to attach and hold himself to the intestinal lining. Laterally
placed, two on each side of the mouth, are lancets which pierce the
flesh, making openings through which the blood can escape. Into the
bite the worm injects a poisonous secretion from a gland in the worm's
head. Besides its poisonous action to the person infected, the poison
keeps the blood from clotting. In the female the generative organs are
anteriorly situated and posteriorly in the male. Eggs are deposited in
immense numbers by the worms and pass out of the intestine with the
excreta.

The harmful effects resulting, then, from the presence of the worm in
the bowel may be numbered as follows:

First. The loss of blood ingested by the worm and the more impor-
tant loss occurring by the oozing for hours of blood from wounds left
by the worm.

Second. The secretion injected by the worm is poisonous.

Third. The wounds of the worm set up .a chronic inflammation
which impairs digestion.

Fourth. Through them entrance into the system by disease produc-
ing bacteria is made easy.

Fifth. Eggs are deposited which, when expelled fro,n the body, de-
velop into infecting worms.

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Figure 8. Selma Ellis seven weeks later after taking the hookworm treatment. He was
able to walk and run; weighed 79 pounds; and during the past winter he has been in school.

Resulting from these harmful effects the host is found to present
certain pronounced symptoms which we shall now consider.

SYMPTOMS OF HOOKWORM DISEASE.

The symptoms of hookworm, disease vary in severity with the degree
and effect of the infection. They may be mild, medium, or severe.
Mild Cases. — In mild cases perhaps no symptoms are observable, and

Figure 9. This shows the head of a hookworm as the parasite is feeding, attached to
the wall of the bowels. (P. H. & M. H. Service.)

unless a microscopic examination reveals the eggs in the stools, the
existence of the disease is not suspected.

Medium Severity. — In medium severity the cases present a recogniz-
able anaemia, and other symptoms seen in severe cases are in sufficient
evidence to suggest the nature of the disease

Severe Cases. — (See Pig. 10.) In severe cases we have presented a
subject so pitiable, so frail, so thin-blooded, so dwarfed mentally and
physically, that the layman who has read of the disease will recog-
nize it.

Stunts Development. — When infection occurs during the growing
age, or before maturity is reached, there is a marked lack of develop-
ment. A child of fourteen years will appear not, over ten.

Body Looks Bloodless. — The skin is white and tallow-like, or some-
times tan-colored. The mucous membranes are pale, often as white as
the skin. The face, body and legs are often bloated. The hair is dry
and brittle. On the head, it is usually normal in quantity, but is scant
in the armpits. In males the beard is scant and poorly developed.
Ulcers and wounds heal slowly.

Appearance of Pace, Eyes and Chest and Abdomen — The face pre-
sents a stupid appearance and the eyes a blank stare, the pupils being
dilated. The tongue is often raw on the edges, and has purplish spots
or seams on its upper surface. The chest is thin, the ribs prominent,
and the shoulder blades stand out as "angel wings." The prominent
abdomen gives rise to such terms as "pot belly," "shad belly," etc.

The Appetite Affected. — The appetite is capricious, being often poor,
often ravenous. Abnormal desire for certain articles of food, as pickles,
salt, buttermilk, etc., is common. In late stages of the disease the appe-

10

tite is so perverted that dirt, clay, plaster, wood, thread, etc., may be
craved and eaten. Diarrhea or constipation may be found, the latter
more commonly.

Other Unpleasant Symptoms. — Palpitation of the heart and other
disorders are common. Headaches are intense, pain on pressure is
present in the pit of the stomach, and from one cause or another the
patient is a constant sufferer. He will tire easily and get out of breath
on exertion. The temperature varies from 97° to 102°, 98 2-5 being
normal. The rise occurs frequently with the onset of the disease, and
as it progresses is occasionally seen, especially in the afternoons. De-
velopment is retarded, girls often being eighteen or nineteen before
passing into womanhood, and even then are frail and flat chested.

Quantity and Quality of Blood Diminished. — The blood is thin,
that is to say, in redness or richness it is often only 20 per cent of
normal; and the number of red blood cells to the drop of blood (one
cubic millimeter) are reduced from the normal number of 5,000,000 to
as low as 745,000 in recorded cases, and there is an eosinophilia in
many cases of as much as 13 per cent, that is to say. there is an ex-
cessive number of a particular kind of white blood cells.

The nervous system suffers with Other portions of the body. The
mind is dull, and the patient suffers with headaches, dizziness, lassi-
tude, insomnia or somnolence. He is likely to be timid and emotional.

A Mental as Well as a Physical Handicap. — In school he is very
backward, at work very irregular and slow. It often requires nine or
more years to complete the usual six years course. It requires all his
power to continue living. Indeed, many fail in this, and either directly
from hookworm disease, or from some intercurrent disease invited by
it, the number who succumb is large.

Prepares Victims for Invasion of Other Death-dealing Maladies. —
Hookworm disease, by sapping the blood, poisoning the body, impair-
ing digestion, and wounding the intestine, robs the body of those quali-
ties necessary for resisting the invasion of other diseases. With its
defenses thus destroyed, it is easily invaded by the death-dealing germs
of tuberculosis, typhoid fever, or pneumonia. Thus thousands of deaths
immediately attributed to the diseases named are in fact due primarily
to hookworm disease. King and Ashford, who, in Porto Rico, have
treated upward of 300,000 cases, hold the disease responsible for 30 per
cent of all the deaths on the island. As a result of their work a re-
duction of the island's death rate shows that 150,000 lives have been
saved. A person mildly infected will perhaps outlive hookworm disease
if he should not become reinfected for ten to fifteen years. The para-
sites do not multiply in the intestine, and in ten to fifteen years die
from old age.

DIAGNOSIS OF HOOKWORM DISEASE.

The Microscope Affords Positive Method for Diagnosis. — The clin-
ical symptoms of hookworm disease in severe cases are all that are

11

Figure 10. Wake County boy, age 16. Photograph taken after he had gained 17J-2
pounds. This increase resulted from one treatment. Paeient still infected, but able to
work six days of the week. Before treatment, was almost completely incapacitated.

12

necessary for making a diagnosis. For mild, and light infections the
microscopic recognition of the eggs in the stools is conclusive. Further
confirmation in all cases can be had by treatment, when the worms are
killed and are found passing in the stools.

TREATMENT OF HOOKWORM DISEASE.

Thymol and Epsom Salts. — The treatment of hookworm disease is a
simple matter. Epsom salts and thymol are the drugs used. The object
desired is to clean the mucous and food particles from the" intestinal
tract, so that the worms will be exposed to the action of the thymol.
This is accomplished by the administration at night of a dose of epsom
salts. Ordinarily, Saturday night is preferred, as it will then cause no
loss of time. In treating children of parents who work out by the day,
the parents will be at home on Sunday. Sunday morning, at 6 a. m.,
one-half of the total dose of thymol in capsules is given; at 8 o'clock
the other half is given, and at 10 a. m. a second dose of epsom salts is
taken. Having cleaned away the mucus from around the worms, the
thymol acts directly on them as a poison. While poisoned, the second
dose of salts sweeps them out of the bowel before enough thymol may
be absorbed by the patient to cause undesirable symptoms.

Caution. — Alcohol and oils are solvents for thymol, and it would be
exceedingly dangerous for either of these to be taken by the patient.
Gravy, butter, milk, etc., must not be taken on days when thymol is
given. Patent medicines contain alcohol, and must be forbidden. The
safe plan to follow is to forbid any food or drink, except water, on the
morning when the thymol is taken.

Moreover, as many hookworm subjects have dilated stomachs, which
do not readily empty themselves, and as it is important that the thymol
reach the small intestine at once, the patient should lie on the right
side for at least a half hour after taking each dose of thymol. The
apparent age, not the actual age, is considered when deciding the size
of the dose. Powder the thymol and give in capsules. If sugar of milk
is added grain for grain with the thymol, the results are more satis-
factory.

DOSE OF THYMOL.

Age

Grains

Grams

0 A. M.

1 to 5 years..

5 to 10 years..
10 to 15 years..
15 to 20 years..
20 to 60 years __
60 and upwards

7.5

15.

1.

.30.

2.

45.

3.

60.

4.

4,

3.

J-2 dose.
Yi dose.
J 2 dose.
}-2 dose.
y-i dose.
Y dose.

y2 dose.
lA dose.
Yi dose.
J'a dose.
Yz dose.
i _> dose.

A dose of ep?om salts at 10 a. m., following the thymol.

13

Male fern, beta-napthol, and other remedies have been used in treat-
ing hookworm disease. Dr. Stiles says we have all we desire in thymol,
and it is probably wise to let well enough alone.

By making an examination for hookworm eggs microscopically after
each dose, it is possible to know when the treatment is finished. If
the microscopic examination can not be made, then the feces can be
examined after each treatment for worms. When no more worms are
seen, one extra dose, for good measure, should be given.

PREVENTION.

Prevent Soil Pollution. — The prevention of hookworm disease will
ultimately require that the soil be protected from pollution. The dirt
must be kept clean. Until this is accomplished, much of the infection
can be prevented by wearing shoes. This, however, does not reach the
foundation necessary to eradicate the disease.

How Prevented. — Sanitary privies (Fig. 11) must be constructed
and used by all the people. This will prevent any further soil pollu-
tion, and the hookworm larvae now living will soon die. Should those
now infected refuse treatment, but could be induced or, if possible,
forced to use sanitary privies, only a few years would be required be-
fore the worms now living would be extinct. The requirements of a
sanitary privy are that it have a water-tight, fly-proof receptacle, and
that the contents of the receptacle be disposed of in a sanitary way. If
not burned, treated with germicides or allowed to ferment in a way
that will mean death to pathogenic organisms. (Write to the North
Carolina State Board of Health, Hookworm Commission, Raleigh, for an
illustrated pamphlet giving plans and specifications for sanitary
privies.)

PREVALENCE OF HOOKWORM IN THE SOUTH.

We have mentioned above all the factors necessary for the prevalence
of hookworm disease and shown that they are found in the South.
People who live in the country, away from sewerage systems, and work
in the soil, suffer more frequently than city residents. Those who go
barefooted, or in other ways allow the skin to come in contact with pol-
luted soil, show a high percentage of infection. In Porto Rico, King
and Ashford reported that probably 90 per cent of the rural population
was infected. Stiles, the discoverer of hookworm in America, and the
leader in the crusade against it, estimates that more than one-third of
the rural population of the South is infected.

PREVALENCE IN NORTH CAROLINA.

Two thirds or more of the physicians of the State have studied the
disease, and are generally in accord in the opinion that one-third of the
rural population suffers from hookworm disease. At this stage of our

14

investigation of the disease in North Carolina we are prepared to say
that it is prevalent in every county in the State.

The investigations made thus far in North Carolina suffice to prove
that no section of the State has escaped the ravages of the disease.

COUNTY INFECTION SURVEYS.

Infection surveys have been completed in thirty-five counties, and
partially completed in many ethers, each of which is based on the
microscopic examination of a minimum of two hundred rural children,
ages six and eighteen years inclusive. The results of the complete
surveys are as follows:

County.

No.

No.

Percentage.

Examined.

Infected.

of Infection.

Beaufort ... .

423

280

66

Bertie . ... .. ... ..

1539

743

48

Bladen __ . .

257

121

50

Burke __ _ _ . _- ..

426 '

252

59

Caldwell

337

214

63

Carteret __ - - ..

1333

860

64

544
263

220
232

40

Columbus -

68

Craven ... _ . _.

1509

828

54

Cumberland- _ -

1537

775

50

225
237

39
175

17

Duplin ___ __ _- —

73

Edgecombe .

1149

421

38

Gates _ -. -

889

318

35

Greene .. .. . ...

544

270

49

Harnett ... ...

763

362

47

Hertford...

389

122

31

Johnston

394

138

35

Martin _ .

1176

542

47

McDowell

287

306

71

Mitchell

210

110

52

Montgomery . -

248

52

20

Nash

1448

731

50

268
612

147
430

51

Pender __ . .

69

Pitt

412

278

67

Randolph _ _ _ .

254

45

17

Robeson _ _._ ._ _ _.

1411

722

51

Rowan... .

246

50

20

Sampson . ___ _ _._

859

68S

80

Wake

1115

534

47

Warren. _ ______ ._

399

163

40

Wayne _. _ _ _ _. ..

1943

1053

54

Wilson... _ _

717

478

67

Yancev... ...

557

175

31

24,920

12,784

51%

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Figure 11. This shows a sanitary privy, designed to prevent the spread of disease. If a
privy of this type were built on every farm and in every yard in villages, and if this privy
were used by all persons, typhoid fever, hookworm disease, and various other maladies
would almost or entirely disappear.

ECONOMIC IMPORTANCE OF HOOKWORM DISEASE.

It is impossible to accurately estimate the economic importance of
hookworm disease. We do not know the number and can not estimate
the value of the lives that, either directly from the disease or indi-
rectly from some intercurrent disease invited by it, have filled acres
of graves that should have remained undug for many years. We can
not estimate the value of the suffering, poor health, incapacitation for
mental or physical work, and other bodily detractions caused by the
disease. We do not know which graves are occupied by great intellect-
ual and financial giants who, undeveloped, were called away by the pre-
ventable and curable disease.

We do know that in proportion to the severity of the disease the
power of the blood to collect oxygen in the lungs and food from the

16

digestive tract and convey this nourishment to the bony, muscular, and
nervous tissue is correspondingly reduced. In a series of more than
five hundred cases of hookworm disease tested in this connection, the
quality of the blood was found to range from 9 to 65 per cent of normal,
the average being less than 50 per cent. When it is reduced to 10 per
cent of normal, or less, the body starves to death. At 75 per cent the
body and mind are, on account of lack of nourishment, incapacitated at
least 25 per cent.

Suppose we stay well within conservative bounds and estimate that
only one-fourth of the North Carolinians have the disease, and that
they have the disease but mildly, on the average the qualities of the
blood being reduced only 25 per cent. Expressed in other words, it
means that in a conservative estimate one-fourth of our people are one-
fourth incapacitated by the disease.

"What, then, is the immense annual loss, in dollars, to the State, aside
from any humanitarian considerations? Time and space will not per-
mit a consideration of the vast loss to the State occasioned along many
lines. Just one specific illustration will be given: In the State public
schools alone, not including colleges, more than $3,000,000 is annu-
ally spent. A per capita division of this sum, according to our estimate,
indicates that one-fourth of the total, or $750,000, is spent on sufferers
from hookworm disease, who are incapacitated to a degree that they
can only assimilate 75 per cent of the learning they would have received
had they not been infected. One-fourth of the money thus spent on
them, or $187,500, is annually lost to the State as a result of the dis-
ease. Think of an annual loss of $187,500 from the school appropria-
tion alone by virtue of the existence of a disease which is both pre-
ventable and curable. Will the State stand by and permit such loss to
continue and not spend more toward its eradication?

STATE LIBRARY OF NORTH CAROLINA

3 3091 00747 7565

PAMPHLET BINDER

ZZ^Z Syracuse, N. Y.
— - Siockton, Calif.

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