Note staring expres

the first few days following its escape from the egg. After the shedding of the skin the young worm is in the stage in which it is capable of entering the human body, which it may do in one of two ways. First, it may be swallowed with contaminated food or water. Secondly, it may get into the body by boring through the skin. In penetrating the skin the embryos produce the condition known as "dew poison" or "ground itch," which is usually the first stage of Hookworm Disease. This "dew poison" is generally on the feet or about the ankles, and it is believed that the wearing of shoes will largely prevent it and protect against Hookworm Disease. After penetrating the skin the worm enters the blood stream, passes through the heart and lungs, makes its way up the wind-pipe or is coughed up and swallowed and after its passage down the gullet into the stomach finally enters the small bowel. This method of entering the body has been demonstrated in actual experiment upon human beings and lower animals. Having reached the site in the body where it elects to reside,

the worm sheds its skin twice more, becomes mature and mates. The eggs have been known to appear in the stools six and one-half weeks after experimental skin infection.

EFFECTS PRODUCED.

The effects produced vary with the intensity of the infection and the condition of the patient. Some individuals are more able to resist the invasion of disease than are others, and this resisting power of the individual determines, to a large extent, the intensity of the symptoms produced in Hookworm Disease.

Cases may be divided into four classes: Light, medium, severe and extreme, depending upon the severity of the symptoms. The light cases

are those in which the infection may not be suspected until proven by a chance microscopical examination. These cases are very numerous and very important from the standpoint of preventive medicine, because they are entirely capable of producing a severe grade of infection in others and of keeping a locality infected. They should all be treated, and it is the duty of every individual living in a community where the disease is known to exist to have an examination of a specimen of his bowel movements to determine whether he is or is not infected. Medium cases are those showing a definite anemia and other symptoms of sufficient severity to bring the patient under the care of a physician. These generally yield to treatment in the most gratifying way. Severe cases are typical. They are pastey-looking, pot-bellied, pop-eyed, stunted, prematurely aged, one er all. They are suspected as hookworm subjects even by the laity. The extreme cases are in danger of death at any time from the severe anemia and other causes dependent upon it. There is no sharp and distinct line to be drawn between these classes, as they grade imperceptibly from one class into the other.

Of course, there are many more of the light cases in Kentucky than there are severe cases, but there can be no doubt that a great number of the children and young adults in our State are suffering from an infection of sufficient severity to cause them to be classified with the severe cases. The work already done by the representatives of the State Board of Health has established the truth of this statement. As a matter of fact the number of extreme cases already found is believed to be large enough to justify the expenditure of time and money thus far made, and those classified as medium which have already had treatment are very numerous. And it is important to remember that the mildest cases are sufficiently weakened to be more liable to contract other diseases.

SYMPTOMS.

In describing the symptoms only those cases which suffer from a grade of infection of sufficient severity to produce active manifestations will be considered. Such cases have been found in every community where the State Board of Health had opportunity to demonstrate them.

General Development.-If the infection occurs before puberty it is very likely to retard the physical and mental development of the child. A boy or girl of sixteen may present the body and mind of one of eight or ten years of age, and young men and women of twenty may appear to be not more than twelve or fifteen.

Skin. The skin of hookworm patients assumes a marked paleness because of the condition of the blood, which we call anemia. In old cases

A Kentucky picture.

the skin may be found dry and wrinkled. Sweat or perspiration may be scanty or even almost entirely suppressed. In the early stages of the disease "ground itch," dew itch or toe itch is often found upon the feet or ankles, and nearly all cases will give a history of having had, at some time, this symptom. It is frequently noted that scratches and minor wounds upon the skin heal very slowly.

Hair. While there may be a normal development of hair upon the nead, there may be a marked scarcity or even entire absence of hair upon other parts of the body where it is normally present.

Swelling. Swelling of the face, feet, ankles, or in extreme cases, of the whole body, may be present. This swelling sometimes disappears very rapidly after treatment and the weight is temporarily reduced as a result of the loss of the accumulation of fluid which is responsible for the swelling.

Expression. The face may wear an expression of anxiety or one of marked stupidity, or may be unchanged.

Thorax. The ribs are, of course, very prominent in emaciated cases. The shoulder blades are prominent and the patient presents a "stooped" appearance.

Digestive System.-The appetite may be very light or it may be ravenous. Sometimes there is complete absence of desire for food, and again it may be next to impossible to satisfy the cravings of the patient. The development of a desire for abnormal articles is often noted, and this is why we hear the sufferers from Hookworm Disease spoken of as "dirt eaters." Lemons, pickles and other sour substances, salt, pepper, sour