globin, but which is not perceptible upon inspection of the patient, but is readily shown by the blood examination. The third or severe type are those cases about which so much has been said in the past, and which have had numerous attacks of ground itch, and usually have several hundreds of the parasites in the intestines, and present all the symptoms of extreme anemia, which is readily recognized without the blood examination, and which is oftentimes so great as to interfere with the development of the individual.

We can not draw a sharp line separating these three types, but I make this classification for the sake of convenience in considering the prevalence of the disease, and also to draw attention to the fact that those cases which can be suspected from the symptoms of profound anemia are not so numerous as the other two types combined.

In cases of the first, or mild type, there are practically no symptoms by which the disease can be suspected. There is no interference with the appetite or digestion which might not be attributed to other causes, no reduction in the hemoglobin, and the patient feels strong and vigorous, as the body is able to nourish a few of the parasites without taxing its reserve power.

In cases of the second type, there may be periods of indigestion but without any marked interference with the appetite. The patient usually says that he feels well and superficial inspection may not detect any anemia, but the blood examination will show the reduction in the blood constituents.

In the third, or severe type, the patient presents all the appearances of profound anemia. The skin has a yellow parchment appearance, mucous membranes are blanched, the sclera shows clear white through the conjunctiva in which no blood-vessels can be made out. The face is bloated and expressionless, and the skin over the exposed

parts often appears to be much thickened and feels dry and rough. The patient may be greatly emaciated, but this may be hidden by edema. The patient is very weak, and if he attempts violent exercise is quickly exhausted and very short of breath. There is a decided systolic murmur, and the blood examination shows a decrease of from 50 per cent. to 90 per cent. in hemoglobin, and the red corpuscles may be as low as 1,000,000 or even less. The appetite is capricious, perverted, and there may be nausea and headache. The perversion of the appetite may be shown in a fondness for clay, meal, sand, or other substances. The food is usually bolted down in large masses which may pass through the alimentary canal without being digested.

In the severe type of the disease, the patient some times becomes so weak that he is scarcely able to drag himself about the house, and there is general edema which is especially marked about the feet, legs and abdomen. He may remain in this condition for some time and then begin to gradually improve, and he may gradually get worse and worse until he dies. These cases have puzzled the physicians in the past, as they were unable to account for the cause of death. When this bloated stage is reached, life seems to hang by a mere thread. Many cases will give a history of having passed through this condition, and the accompanying photograph shows a patient seen in the mountains of North Georgia who was twenty years of age and who gave a history of having passed through this bloated stage four years ago, and since which time he had gradually improved. While he still has the appearance of a boy twelve or thirteen years of age, and there is no growth of hair upon the face or genitals, the testicles show signs of beginning development.

DIAGNOSIS.

A positive diagnosis of the disease can only be made by finding the eggs of the parasite in the stools of the patient.

In the mild type of cases there is absolutely nothing in the appearance of the patient that would lead one to suspect the presence of the disease, and there are no diagnostic subjective symptoms; and in cases of the second type

this is almost equally as true. At best you may be able to detect a slight paleness of the mucous membranes, but of course this alone does not make a diagnosis.

The severe type presents all the symptoms which we find in all cases of profound anemia, and there is nothing positively distinctive about this anemia which separates the disease from the profound anemias due to other causes. If any one should stake his reputation upon his ability to differentiate the severe type of this disease from profound anemia due to other causes he would be sure to come to grief.

There is an important point upon which I wish to lay great stress. Where you find one case of the severe type of the disease you will find a much greater number of the mild and medium type. The severe cases are far in the minority and represent only a small proportion of the great mass of cases of all types of the disease. Usually you do not find more than one case of the severe type in one family, and yet all the other children may be infected, but not be suspected on account of being of the mild or medium type and not presenting any pronounced symp. toms. Too much stress has been laid upon the severe type to the almost entire exclusion from consideration of the milder types, with the result that the physicians are not on the lookout for the disease unless they see these symptoms of severe anemia. But the symptoms presented in these severe cases are simply the conditions which you would find with any profound anemia due to almost any cause, and are not diagnostic of the disease.

Until recently all these cases of extreme anemia, delayed development, parchment skin, etc., have been called malarial cachexia, and treated as such, but now, as soon as a doctor gains a little knowledge of uncinariasis he is prone to call all these cases hookworm disease, and proceeds blindly to dose them with thymol. The pendu

lum always swings from one extreme to the other, but eventually it will settle upon rational middle ground.

While it is true that the doctor who makes a snap diagnosis and calls every case of profound anemia uncinariasis will be correct in the majority of instances, yet he will also be surprised at the number of times he will find that he is mistaken, and that his treatment is of no avail. This being the case, no doctor is warranted in indiscriminately prescribing these large toxic doses of thymol without first being sure of his diagnosis; and especially so in view of the fact that a positive diagnosis can be made with such ease and accuracy.

THE DISEASE NOT CONFINED TO THE LOWER CLASSES.

While this is a disease of the country and not of the city, and is most commonly found among the lower classes, yet I find that it bobs up in the better classes and in the cities, and often in the most unexpected quarter. Every physician must be always on the alert if he would be sure that no case slips through his hands undiagnosed, but disguised by an attack of some other disease. It is the joy of every boy, whether rich or poor, to go barefoot in the summer, and to paddle about in the mud, and many who live in the cities spend their summers in the country, and while there contract ground itch and in this way have the mild or medium type of the disease.

MODE OF ENTRANCE OF PARASITE INTO THE HUMAN BODY.

To cope with this disease intelligently so as to prevent its further spread, it is necessary for us to know by what means the parasite gets into the human body. As we find the adult worms clinging to the mucous membrane of the small intestines, we would naturally suppose that they reached this part of the alimentary canal by being taken into the mouth in some way and passing into the esophagus and stomach and then attach themselves to the small