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Patient Centered Clinical Care For African Americans A Concise Evidence Based Guide To Important Differences and Better Outcomes Gregory L. Hall
Patient Centered Clinical Care For African Americans A Concise Evidence Based Guide To Important Differences and Better Outcomes Gregory L. Hall
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Patient-Centered
Clinical Care for
African Americans
A Concise, Evidence-Based
Guide to Important
Differences and Better
Outcomes
Gregory L. Hall
123
Patient-Centered Clinical Care for African
Americans
Gregory L. Hall
Patient-Centered Clinical
Care for African Americans
A Concise, Evidence-Based Guide
to Important Differences and Better
Outcomes
Gregory L. Hall, MD
Partnerships for Urban Health
Cleveland State University
Cleveland, OH
USA
This Springer imprint is published by the registered company Springer Nature Switzerland AG
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
This book is dedicated to my wife, Melanie,
and our sons, Alex, Nick, and Greg Jr., for all
of their sacrifice and unwavering support.
Preface
In the fall of 2002, I was appointed to the Ohio Commission on Minority Health.
My name had been submitted to Ohio Governor Bob Taft by Cleveland’s Mayor
Jane Campbell because they needed a medical professional from the Cleveland area
to better balance the representation to the state-wide board. As a Cleveland Clinic-
trained internal medicine and primary care provider in an urban practice that was
over 90% African American, I could provide in-the-trenches perspectives. Upon
joining, I was embarrassed to admit how little I knew about health disparities and
how they impacted minorities, but I attended the meetings regularly … and
quietly.
The commission was largely a funding organization and specialized in advanc-
ing smaller grants for unique approaches to shrinking health disparities. We also
advocated for policies that impact health in the larger scheme. The commission is
composed of the directors of key statewide departments including the Departments
of Health, Job and Family Services, Education, Medicaid, Developmental
Disabilities, and Mental Health and Addiction, in addition to four elected officials
and eight governor appointees, of which I was one.
Bringing a “high-end” group like this together was initially intimidating but
before long we began to fill our roles appropriately. As a physician, I initially
believed that health disparities were almost completely driven by poverty and/or the
lack of access to medical services. I also falsely believed that “minorities” had poor
health outcomes and the “majority” populations had better health outcomes.
Because of my work with the commission, I soon joined the Medical Care
Advisory Committee for Ohio Medicaid. In this capacity, I saw not only the finan-
cial burden that poor health outcomes put on a strained state budget but also the
disconnect between providers of Medicaid recipients and state agency representa-
tives with good intentions.
My exposure to the breadth of urban healthcare delivery was rounded by my
experience as medical director of multiple urban extended care facilities including
two with large psychiatric populations, continued inpatient care with patients at an
vii
viii Preface
inner city hospital (St. Vincent Charity Medical Center), and some time as medical
director of home health and hospice agencies.
As the years passed, I was elected vice-chair and then chairman of the Ohio
Commission on Minority Health. A part of my duties was to prepare an educational
chairman’s report to be presented at each meeting. As I became familiarized with
research articles involving quality outcomes, I was struck by the significant health
disparities between minority groups and that the specific health issues were not
addressed by the same solutions. Problems in the Asian American or Hispanic/
Latino communities consisted of issues regarding immigration, communication,
language, and access. African American disparities were pervasive across a range of
categories: the worst cardiovascular issues, worst cancer outcomes, longest length
of hospital stay, lowest referrals for accelerated care, and so on. Put simply, the
health-related problems for African Americans were too serious, too unique, and too
severe to simply be “bunched” with other racial/ethnic groups.
My second revelation was that physicians, clinicians, and other providers were
indirectly contributing to some of these disparities. This perspective was first
brought to my attention by the Commission Executive Director Cheryl Boyce, who
had noted these differences from both a professional and a personal perspective. I
remember initially shrugging off her viewpoint as isolated because variability in
care delivery can occur, but when I reviewed the wide-ranging research, the perva-
sive clinician-driven differences in the care of African Americans were undeniable.
I decided to highlight some of these care differences on my practice website,
drgreghall.com, in order to educate the African American community to be better
stewards of their medical care. As I composed these short articles with hyper-
links to verified research in PubMed, I was progressively finding more nuances
in clinical care.
I realized that my aim to educate about the differences in the clinical care of
African Americans was directed to the wrong audience, and I needed to move
“upstream” and bring these differences to the notice of medical providers. That
realization soon led to the process of compiling a collection of best practices for
African American clinical care, one that is long overdue and deserving of the medi-
cal community’s singular attention.
This book was definitely a group effort and the culmination of a number of partner-
ships and affiliations across my career. I started the book by interviewing a number
of highly successful physicians who had predominant African American patient
populations. As a provider for African Americans, I knew that my approach to this
patient population was different, but I needed to know if there was a distinct pattern.
I particularly appreciate the input of Ronald Adams, MD; Lloyd Cook, MD; Giesele
Greene, MD; Carl Jackson, MD; Toye Williams, MD; and Harold James, MD, for
their assistance early on. I also need to thank my brother, Bill Hall, for introducing
me to his physician colleagues for interviews in the Maryland region including
Elmer Carreno, MD; Geoff Mount-Varner, MD; and Don Shell, MD. Another
important interview was with my good friend since our Cleveland Clinic residency
days, Mark Spears, MD, in Florida.
Many thanks to my colleagues and the staff at St. Vincent Charity Medical Center
including Chief Medical Officer Joseph Sopko, MD, one of the earliest reviewers;
Department of Medicine Chairman Keyvan Ravakha, MD; and supportive col-
leagues, Mukul Pandit, MD; Donald Eghobamien, MD; Sam Ballesteros, MD; Alan
Rosenfield, MD; Mona Reed, MD; Jill Barry, MD; James Boyle, MD; John Marshall,
MD; Emmanuel Elueze, MD; Oluwaseun Opelami, MD; and Lonnie Marsh, MD.
The residency program at St. Vincent Charity Medical Center produces top-
notch physicians who also contributed to this book. Randol Kennedy, MD, and
Anita Mason-Kennedy, MD, reviewed and added to the entire book with particular
contributions to the chapters on cardiology, hematology, and rheumatology. I also
appreciate and thank graduate Medical Education Manager Nicole Allen-Banks.
Other residents proofreading include Nana Yaa, MD, and Adeyinka Owoyele, MD.
My cousin, Kim Simpson, MD, was my first reviewer and got this book off to a
great start particularly contributing to the first three chapters. Good friend Joan
Reeder, MD, also reviewed the book early on.
ix
x Acknowledgments
I was honored to have the chapters on cardiovascular and renal disease reviewed
with significant input by Jackson T. Wright Jr., MD, PhD. Sherrie Dixon-Williams,
MD, reviewed and contributed to the pulmonary chapter.
I appreciate the ongoing support of Janet Baker, DNP, dean of Ursuline College
School of Nursing, for her support in reviewing the book. The chapter on stories and
patient counseling was reviewed by William Tarter Sr., and I appreciate his ongoing
guidance and counsel.
I would also like to express my gratitude to Cheryl and Russel Boyce; Nick and
Yvette Petty; Thomas Ferkovic; Georgia State Senator Emanuel Jones; Georgia
State Rep. Al Williams; Donald Wesson, MD, MBA; John McCarthy; Charles
Modlin, MD; Angela Cornelius Dawson; Cora Munoz, PhD, RN; Danny Williams;
Deborah Enty; Mary E. Weems, PhD; Michael Oatman; Reggie Blue, PhD; Paul
Lecat, MD; David Whitaker, JD; Tim Goler, PhD; Robert Ankrum; Ronald Duncan;
Robert Dennison; Earl King; Terry Ford; Alana Smith; and a host of other physi-
cians, nurses, and professionals with whom I work in various capacities.
My office practice would not be able to stay afloat without my office manager,
Robin Smith, holding everything together. Medical Assistant Jasmine Williams
always has a happy and caring smile for both my patients and I. My long-term
administrative assistant, Katrina Hurt, also deserves credit for her support over the
years. I am also grateful to my patients who have supported my work and encour-
aged me. My patients are the best in the world, and I treasure their support and
commitment.
My position as co-director of the Northeast Ohio Medical University-Cleveland
State University Partnership for Urban Health has allowed me to work with an out-
standing array of people. My predecessor in this position is a modern medicine leg-
end and is dedicated to excellence and inclusion in all he does, Edgar Jackson Jr.,
MD. Ronnie Dunn, PhD, is an outstanding leader in diversity and inclusion and was
very instrumental in getting this book published. Celeste Ribbons is an outstanding
operations manager, organizer, and counselor. Lena Grafton is an excellent teacher,
researcher, and outreach officer. Antoinette Speed does a great job keeping us orga-
nized and successful in our projects. Peggy Irwin is an outstanding grant writer,
teacher, and manager. Dr. Julian Earls has been a constant inspiration to me and is a
champion among educators. School of Health Sciences Director Beth Domholdt is
the perfect collaborator due to her insight, experience, and compassion. Dean
Meredith Bond of the College of Sciences and Health Professions has also been very
supportive of our work and has great intuition and knowledge. My sincere thanks
also go to the provost of Cleveland State University, Jianping Zhu, PhD.
Acknowledgments xi
xiii
xiv Contents
Index�������������������������������������������������������������������������������������������������������������������� 215
Why Is Patient-Centered Culturally
Competent Care Important? 1
Despite countless social and societal norms, we are all different. Having a book that
advances generalizations based on race or ethnicity can be a risky and potentially
inflammatory endeavor. Whenever you generalize about people, there are going to
be glaring exceptions that can be embarrassing, hurtful to the patient, and, above all,
counter-productive. I remember asking an 80-year-old new patient what her mother
died from. And seeing the look on her face, that initially suggested I knew some-
thing that she did not. And her reply was “my 97-year-old mother was fine when I
left her this morning.”
On the positive side, some generalizations can consistently be assumed. The
patient-centered movement has placed respect and consideration of the patient as
a central tenet, and it would be hard to find those who would disagree with this
approach.
It is important to note that I am fully aware of the “danger” of classifying a race/
ethnic group as homogenous. Chinedu Ejike discussed these potential inaccuracies
in his article about chronic obstructive pulmonary disease (COPD) in America’s
“Black” population:
Currently, Blacks in America are a rapidly growing subset of the U.S. population and the
growing black immigrant population has recently fueled this growth. COPD prevalence and
morbidity vary widely among African Americans (U.S. born blacks) versus black immi-
grants (foreign-born blacks), but most studies have treated blacks in America as a homoge-
neous “African-American” population. This assumption ignores the disparities in
socioeconomic status, tobacco or biomass smoke exposure, social behaviors, access to
healthcare, health insurance coverage and disease management present among the sub-
groups of blacks in America. The use of “African American” to describe all U.S. blacks in
the majority of observational and interventional studies should be avoided and better
stratification performed in studies moving forward to allow for the design of effective pre-
ventive and therapeutic interventions. [1]
Dr. Ejike is completely correct, and his view represents the perspective of many
providers and researchers. A more nuanced approach would definitely be more
appropriate. This book, however, cites “evidence-based” research where “differ-
ences” based on race/ethnicity existed however it was defined. When population
differences did not achieve statistical significance, it was likely because of the
heterogenicity inherent in almost any racial/ethnic group in the United States. In
order for differences to exist, a statistical difference had to exist, and with African
American health differences, many of these differences are unequivocal.
This book is thin because in the world of medicine, humans are far more alike
than different. Many of the important differences in the care of African Americans
involve giving more attention to certain details of their care. Screen more vigilantly
for cancer, spend more time on smoking cessation, think about lupus, sarcoidosis,
and other rare disorders when you are frustrated by an odd patient presentation. This
approach is no different than “thinking of Lyme disease” when a patient presents
with complaints after camping in New England. Lyme disease can be transmitted in
numerous places across the United States, but providers are trained to particularly
look for oddball diseases in these cases because the likelihood is supposed to be
higher.
Some of the important differences we see in African Americans are based on
minor genetic differences like sickle cell anemia and others. Other differences are
based on diet, environmental exposures, poverty, lifestyle choices, and more. These
differences are not to be applied blindly to every patient you see, but instead are
to be “considered.” By simply considering these important differences, improved
clinical care outcomes across a population will ensue.
The Institute of Medicine’s Unequal Treatment: Confronting Racial and Ethnic
Disparities in Health Care section on cross-cultural communication describes the
benefit:
Sociocultural differences between patient and provider influence communication and clini-
cal decision-making. Evidence suggests that provider-patient communication is directly
linked to patient satisfaction, adherence, and subsequently, health outcomes. Thus, when
sociocultural differences between patient and provider aren’t appreciated, explored, under-
stood, or communicated in the medical encounter, the result is patient dissatisfaction, poor
adherence, poorer health outcomes, and racial/ethnic disparities in care. And it is not only
the patient’s culture that matters; the provider “culture” is equally important. Historical
14 2 Establishing Trust
Fortunately, the level of trust a patient has for any specific provider is not stag-
nant, it can be earned. Increased exposure to providers in general, and to the same
provider in specific, has been shown to improve trust.
Studies have also shown that racial concordance positively impacts the level of
trust for a same race patient [12]. In simpler terms, African American patients are
initially more trustful of African American providers. Those non-African American
providers can, and do, achieve high levels of trust with African American patients,
but doing so usually takes a little more effort.
African American providers have a distinct advantage over others in the level
of trust at the very beginning of their provider-patient relationship because of their
mutual cultural history. As African Americans, there is clearly a perception of com-
parable mutual interests, as well as a less perceived difference in power. Clearer
2.4 Trust Improves Health Outcomes 15
communication may also come from the better translation of complicated medical
concepts into terms and analogies that have a similar cultural basis in the African
American experience.
Thom goes on to explain how a provider can achieve these components of trust:
All of these associations suggest approaches that would be expected to increase patient
trust, such as emphasizing mutual interests (the patient’s health); checking patients’ under-
standing of communication; taking opportunities to fulfill trust (phoning with test results);
reducing power differences (sharing information); responding to patients’ self-disclosures
in a supportive and nonjudgmental way; and promoting continuity of care. [15]
There are also differences in the acceptance of personal disclosures across racial
lines with African Americans physicians being more tolerant of disclosures that
may be more pervasive in their social community. The disclosure that a patient
was raised in a single-parent family and has “no idea” what medical problems their
father has may flow more smoothly to an African American provider who would be
perceived as having a higher likelihood of not stigmatizing that history.
African American patients are also generally on guard for biases whether
conscious or unconscious. More formally known as explicit and implicit biases,
researchers have looked at the impact bias can have on the quality of patient encoun-
ters. Implicit biases are subconscious, whereas explicit biases are those that the prac-
titioner is fully aware of. Providers may have an explicit bias against patients that
were child molesters (as one extreme example) or against patients that are unem-
ployed and presumably not seeking work (a subtler example). When a provider has
an explicit bias, one that they admit to themselves and others, they typically work
to minimize the effect of the bias on their quality of care. What is presumed is the
provider’s ability to work through those acknowledged explicit biases and still work
for the full benefit of the patient.
Implicit biases are attitudes and stereotypes that impact our care delivery, dis-
cussion, and decisions in an unconscious manner. As noted by the Kirwan Institute
for the Study of Race and Ethnicity at The Ohio State University, “implicit biases
are pervasive. Everyone possesses them, even people with avowed commitments to
impartiality such as judges.” They go on to propose that “the implicit associations
we hold do not necessarily align with our declared beliefs or even reflect stances we
would explicitly endorse [16].” So many of us have no idea what our implicit biases
may be … what is important is to accept that they exist and to work to get a better
understanding for how they impact the care we provide.
In the “Medscape Internist Lifestyle Report 2017,” Carol Peckham looked at
internist’s admitted explicit biases “toward specific types or groups of patients”
Another random document with
no related content on Scribd:
Tracheate Arachnids, with the last three segments of the
cephalothorax free and the abdomen segmented. The chelicerae are
largely developed and chelate, and the pedipalpi are leg-like,
possessing terminal sense-organs.
The Solifugae are, in some respects, the most primitive of the
tracheate Arachnida. Their general appearance is very spider-like,
and by the old writers they are uniformly alluded to as spiders. The
segmented body and the absence of spinning organs, however, make
them readily distinguishable on careful inspection. They are for the
most part nocturnal creatures, though some seem to rove about by
day, and are even called “Sun-spiders” by the Spaniards. The night-
loving species are attracted by light. They are, as a rule, exceedingly
hairy. Some are extremely active, while the short-legged forms (e.g.
Rhagodes, see p. 429) move slowly. They are capable of producing a
hissing sound by the rubbing together of their chelicerae. Only the
last three pairs of legs are true ambulatory organs, the first being
carried aloft like the pedipalps, and used for feeling and
manipulating the prey.
There has been much controversy as to the poisonous properties
with which these creatures have been very widely credited by both
ancient and modern writers. The people of Baku on the Caspian
consider them especially poisonous after their winter sleep. The
Russians of that region much dread the “Falangas,” as they call them,
and keep a Falanga preserved in oil as an antidote to the bite. The
Somalis, on the other hand, have no fear of them, and, though
familiar with these animals, have not thought them worthy of the
dignity of a name.
Several investigators have allowed themselves to be bitten without
any special result. Some zoologists have found and described what
they have taken to be poison-glands, but these appear to be the coxal
glands, which have an excretory function. Bernard[325] suggests that,
if the bite be poisonous, the virus may exude from the numerous
setal pores which are found on the extremities of the chelicerae. The
cutting powers of the immensely-developed chelicerae are usually
sufficient to ensure fatal results on small animals without the agency
of poison. Distant,[326] indeed, thinks they cannot be poisonous, for
when birds attack them they flee before their assailants.
The Solifugae require a tolerably warm climate. In Europe they are
only found in Spain, Greece, and Southern Russia. They abound
throughout Africa, and are found in South-Western Asia, the
southern United States, and the north of South America. They
appear to be absent from Australia, nor have any been found in
Madagascar. Their usual food appears to be insects, though they
devour lizards with avidity. Some interesting observations on their
habits are recorded by Captain Hutton,[327] who kept specimens in
captivity in India. An imprisoned female made a burrow in the earth
with which her cage was provided, and laid fifty eggs, which hatched
in a fortnight, but the young remained motionless for three weeks
longer, when they underwent their first moult, and became active.
A sparrow and musk rats were at different times placed in the
cage, and were speedily killed, but not eaten. Two specimens placed
in the same cage tried to avoid each other, but, on coming into
contact, fought desperately, the one ultimately devouring the other.
It was noteworthy that the one which was first fairly seized
immediately resigned itself to its fate without a struggle. As is the
case with some spiders, the female is said occasionally to kill and
devour the male. A Mashonaland species, Solpuga sericea, feeds on
termites,[328] while a South Californian Galeodes kills bees,[329]
entering the hives in search of them. They are fairly good climbers.
In Egypt Galeodes arabs climbs on to tables to catch flies, and some
species have been observed to climb trees.
That their pedipalps, in addition to their sensory function (see p.
426), possess a sucking apparatus, is clear from an observation of
Lönnberg,[330] who kept specimens of Galeodes araneoides
imprisoned in rectangular glass boxes, up the perpendicular sides of
which they were able to climb for some distance by their palps, but,
being able to obtain no hold by their legs, they soon tired.
External Anatomy.—The body of Galeodes consists of a
cephalothorax and an abdomen, both portions being distinctly
segmented. The cephalothorax consists of six segments, the first
thoracic segment being fused with the two cephalic segments to form
a sort of head, while the last three thoracic segments are free, and
there is almost as much freedom of movement between the last two
thoracic segments as between the thorax and the abdomen. The
“cephalic lobes,” which give the appearance of a head, have been
shown by Bernard[331] to be due to
the enormous development of the
chelicerae, by the muscles of
which they are entirely occupied.
The floor of the cephalothorax
is for the most part formed by the
coxae of the appendages, and the
sternum is hardly recognisable in
many species. In Solpuga,
however (see p. 429), it exists in
the form of a long narrow plate of
three segments, ending anteriorly
in a lancet-shaped labium.
A pair of large simple eyes are
borne on a prominence in the
middle of the anterior portion of
the cephalothorax, and there are
Fig. 217.—Rhagodes sp., ventral view. often one or two pairs of vestigial
Nat. size. a, Anus; ch, chelicerae; g.o, lateral eyes.
genital operculum; n, racket organs; p, The first pair of tracheal
pedipalp; 1, 2, 3, 4, ambulatory legs. stigmata are to be found behind
(After Bernard.)
the coxae of the second legs.
The mouth-parts take the form
of a characteristic beak, consisting of a labrum and a labium entirely
fused along their sides. The mouth is at the extremity of the beak,
and is furnished with a straining apparatus of complicated hairs.
The abdomen possesses ten free segments, marked off by dorsal
and ventral plates, with a wide membranous lateral interval. The
ventral plates are paired, the first pair forming the genital opercula,
while behind the second and third are two pairs of stigmata. Some
species have a single median stigma on the fourth segment, but this
is in some cases permanently closed, and in the genus Rhagodes
entirely absent, so that it would seem to be a disappearing structure.
The appendages are the six pairs common to all Arachnids—
chelicerae, pedipalpi, and four pairs of legs. The chelicerae, which
are enormously developed, are two-jointed and chelate, the distal
joint being articulated beneath the produced basal joint. In the male
there is nearly always present, on the basal joint, a remarkable
structure of modified hairs called the “flagellum,” and believed to be
sensory. It differs in the different genera, and is only absent in the
Eremobatinae (see p. 429). The pedipalpi are strong, six-jointed, leg-
like appendages, without terminal claw. They end in a knob-like
joint, sometimes movable, sometimes fixed, which contains a very
remarkable eversible sense-organ, which is probably olfactory. It is
concealed by a lid-like structure, and when protruded is seen to be
furnished, on its under surface, with a pile of velvet-like sensory
hairs.
The legs differ in the number of their joints, as the third and fourth
pairs have the femora divided, and the tarsus jointed. The first pair
has only a very small terminal claw, but two well-developed claws are
borne by the tarsi of the other legs. Each of the last legs bears, on its
under surface, five “racket organs,” believed to be sensory.
Internal Structure.—The alimentary canal possesses a sucking
chamber within the beak, after which it narrows to pass through the
nerve-mass, and after an S-shaped fold, joins the mid-gut. This gives
off four pairs of thin diverticula towards the legs, the last two
entering the coxae of the third and fourth pairs.
At the constriction between the cephalothorax and the abdomen
there is no true pedicle, but there is a transverse septum or
“diaphragm,” through which the blood-vessel, tracheal nerves, and
alimentary canal pass. The gut narrows here, and, on entering the
abdomen, proceeds straight to a stercoral pocket at the hind end of
the animal, but gives off, at the commencement, two long lateral
diverticula, which run backwards parallel with the main trunk. These
are furnished with innumerable secondary tube-like diverticula,
which proceed in all directions and fill every available portion of the
abdomen. The caeca, which are so characteristic of the Arachnidan
mid-gut, here reach their extreme development. A pair of Malpighian
tubules enter the main trunk in the fourth abdominal segment.
Other excretory organs are the coxal glands, which form many
coils behind the nerve-mass, and open between the coxae of the third
and fourth legs. They have been taken for poison-glands.
There is a small endosternite in the hinder portion of the
cephalothorax under the alimentary canal.
The vascular system is not completely understood. The heart is a
very long, narrow, dorsal tube, extending almost the entire length of
the animal, and possessing eight pairs of ostia, two in the
cephalothorax and six in the abdomen. It gives off an anterior and a
posterior vessel, the latter apparently a vein, as it is guarded at its
entrance by a valve. The blood seems to be delivered by the anterior
artery on to the nerve-mass, and, after percolating the muscles and
viscera, to divide into two streams—the one returning to the heart by
the thoracic ostia, the other passing through the diaphragm and
bathing the abdominal organs, finally to reach the heart either by the
abdominal ostia or by the posterior vein.
The nervous system, notwithstanding the fact that the three last
thoracic segments are free, is chiefly concentrated into a mass
surrounding the oesophagus. Nerves are given off in front to the
eyes, the labrum, and the chelicerae, while double nerves radiate to
the pedipalps and to the legs. From behind the nerve-mass three
nerves emerge, and pass through the diaphragm to enter the
abdomen. The median nerve swells into an “abdominal ganglion”
just behind the diaphragm, and is then distributed to the diverticula
of the alimentary canal. The lateral nerves innervate the generative
organs.
The respiratory system consists of a connected network of tracheae
communicating with the exterior by the stigmata, whose position has
already been described. There are two main lateral trunks extending
nearly the whole length of the body, and giving off numerous
ramifications, the most important of which are in the cephalothorax,
and supply the muscles of the chelicerae and of the other
appendages.
The generative glands do not essentially differ from the usual
Arachnid type, though the paired ovaries do not fuse to form a ring.
There are no external organs, and the sexes can only be distinguished
by secondary characteristics, such as the “flagellum” already
mentioned.
Classification.—There are about a hundred and seventy species
of Solifugae inhabiting the warm regions of the earth. No member of
the group is found in England, or in any except the most southern
portions of Europe.
Kraepelin[332] has divided the
group into three families—
Galeodidae, Solpugidae, and
Hexisopodidae.
Fam. 1. Galeodidae.—The
Galeodidae have a lancet-shaped
flagellum, directed backwards.
There is a characteristic five-
toothed plate or comb covering
the abdominal stigmata. The
tarsus of the fourth leg is three-
jointed, and the terminal claws
are hairy.
There are two genera,
Galeodes, with about twelve
species, and Paragaleodes, with
six species, scattered over the hot
regions of the Old World.
Fam. 2. Solpugidae.—The
Solpugidae comprise twenty-four
genera, distributed under five
sub-families. The toothed
stigmatic plate is absent, and the
tarsal claws are smooth. The
ocular eminence is furnished with
irregular hairs. The “flagellum” is
Fig. 218.—Nervous system of Galeodes.
very variable. abd.g, Abdominal ganglion; ch,
(i.) The Rhagodinae include cheliceral nerve; ch.f, chitinous fold;
the two genera, Rhagodes (Rhax) ch.r, chitinous rod; g.n, generative
and Dinorhax. The first has nerve; l, labial nerve; st, position of
twenty-two species, which inhabit stigma. (After Bernard.)
Africa and Asia. The single
species of Dinorhax belongs to East Asia. These creatures are short-
legged and sluggish.
(ii.) The Solpuginae contain two genera—Solpuga with about fifty
species, and Zeriana with three. They are all inhabitants of Africa,
and some occur on the African shore of the Mediterranean.
(iii.) The Daesiinae number
about forty species, divided
among several genera, among
which the principal are Daesia,
Gluvia, and Gnosippus. They are
found in tropical regions of both
the Old and the New World.
(iv.) The Eremobatinae are
North American forms, the single
genus Eremobates numbering
about twenty species. The
Fig. 219.—Chelicera and flagellum of flagellum is here entirely absent.
Galeodes. (After Kraepelin.) (v.) The Karshiinae include
the five genera Ceroma,
Gylippus, Barrus, Eusimonia, and Karshia. They are universally
distributed.
Fam. 3. Hexisopodidae.—This family is formed for the
reception of a single aberrant African genus, Hexisopus, of which five
species have been described.
There are no claws on the tarsus of the fourth leg, which is beset
with short spine-like hairs, and in other respects the genus is
peculiar.
Fig. 220.—Chelicerae and flagella of A,
Rhagodes; B, Solpuga; and C, Daesia.
(After Kraepelin.)
Fig. 221.—Chelicera and flagellum of
Hexisopus. (After Kraepelin.)
(CHERNETES, PSEUDOSCORPIONES.)