Indiana may well be proud of her medical boys in New York hospitals.

Some day our Indiana University Medical School will present equal facilities. Most of the leading men in Indianapolis practice are also graduates of our local hospitals. But the best training is still in the old City Hospital-mother of all the later hospitals. A. W. B.

THREE REQUESTS.

A P. M. G. reader sent us the following little story-certainly one of the best of its kind:

To the great god Buddha came the representatives of the Catholic, Protestant and Jewish religions, to pay him homage. Buddha, very flattered, told each of them that if they would express a wish, it would be fulfilled.

"What do you wish?" he asked the Catholic.

The answer was "Glory."

"You shall have it," said Buddha and turning to the Protestant, "What do you wish?"

SYMPTOMS

AND TREATMENT OF HOOKWORM DISEASE.*

By J. Russell Perkins, M.D., Spencer, Va. This being such a widespread disease in the Southern States, destroying the energy, vitality and lives of so many of our patients, it is certainly time that every physician should be familiar enough with its symptoms to be able to diagnose even the mildest cases. The disease is becoming so well known that even some laymen are able to diagnose the marked cases. I do not think a physician should consider himself an expert or congratulate himself on having diagnosed a few pronounced cases, as these are very plain and can be diagnosed at once on inspection, without the aid of the microscope. The cases we should be able to recognize are the mild and moderately severe ones, which do not show the pallor and other symptoms which we usually expect and look for in hookworm dis

ease.

I shall not deal with the prevalence or preventation, as this very important part of the subject has been assigned to one who has canvassed the hookworm district of Virginia, and who is far better qualified to deal with the subject than I; therefore, I wish mainly to speak of the symptoms and treatment.

I know of no disease which gives such The a variety of symptoms as this. sucker, the hookworm being a blood symptoms are due in a large measure to loss of blood. Anemia following the loss

*Read by title before the forty-first annual session of the Medical Society of Virginia, at Norfolk, Va., October 2528, 1910. The above article from the Virginia Medical Semi-Monthly of Nov. 25, 1910, is the best article I have seen on Hookworm disease, which is also found in southern Indiana carried by A. W. B. movers.

of blood, of course, gives rise to other symptoms, and according to the best authorities a toxin seems also to play an important part in the destruction of the blood.

Dock and Bass, in their work on hookworm disease, divide these cases into slight, moderate and severe.

The slight cases are hardest to recognize as they have not the pallor and other marked symptoms. About the only noticeable symptoms are slight digestive disturbances, reduction in the hemoglobin, slight indisposition to work and the presence of eggs in the feces. In some subjects none of the above symptoms disturbance exist except the digestive

and the presence of eggs in the feces. These patients do not realize that there is anything wrong, and will tell you that they are in perfect health, but if they can be persuaded to take the treatment they soon realize their condition. They begin to feel better at once, and invariably increase in weight. This class of patients have been termed hokworm carriers and are a source of as much danger as the severest case, as they continue to deposit the eggs on the soil, which in turn develop the larvae by the thousands and reinfect the patient himself or other members of the family. I have had patients of this class to gain as much as fifteen to twenty pounds inside of a few months.

The moderate cases are the ones we see almost every day; the symptoms just mentioned are much more prominent; we find the peculiar facial expression-the tallow face, all the mucous membranes are anemic, the patient has no energy; if in an adult he is called lazy, is indisposed to work; if in child the parent will tell you that the child will not play around with the other children; some will say that they have no pain, but just do not feel able to do anything at all.

The majority, however, will complain of some pain, especially in the epigastric region and in the joints. Shortness of breath on exertion and palpitation of the heart are most always present in moderate cases; hemic murmesr are often heard, and the mental condition is not up to the average child of his age. Most of them, will give a history of ground itch, which is nothing more than an infection caused by the penetration of hookworm larvae. Sometimes they will apply for treatment for these sores; one of my recent cases, a mother of five children, all of whom were hookworm subjects, came to my office for treatment, and had them on both forearms from the size of a dime to the size of a dollar. I can recall another case in a young girl, who had them on both breasts and in each axilla. The most usual locations, though, are between and under the toes and about the ankles. In small children we sometimes see these lesions on the buttocks; children in the country, especially the poorer classes, often wear only one garment; they sit and play in the dirt and get the infection in that way. Pus is often found in these sores, which is due to secondary infection caused by scratching, as the penetration of the larvae causes intense itching.

Another frequent symptom I have noticed is an increase in the flow of urine; one patient came to me for treatment, who had been treated several months for diabetes, and I, too, thought he had the disease, until an examination of the urine and feces was made. Enuresis is an occasional symptom. I have relieved three obstinate cases with thymol. Disturbed sleep and night terrors are also

common.

Some patients seem to overcome the disease to a great extent without treatment where there is no reinfection, as the worm in the intestine will finally die. The subject may move into a district not infected, or change his occupation, avoiding reinfection in that way. Cases that do not take this course usually gradually go into the severe form. In this form the patient is in a very weak

condition, the skin appears to be almost bloodless, edema of the feet anl legs is commonly noted, sometimes extending to the abdomen, and especially under the lower eyelids. The digestive disturbances are worse than in the moderate cases, diarrhea, constipation and sometimes bloody stools appear. 1 have seen blood in the stools from two patients. Pulsations in the neck are so marked that they may be seen across the room, haemic murmurs are more audible, epigastric pain is more marked, fainting spells, headache and blurred vision are almost constant.

In young girls menstruation is delayed; if it appears at all it is irregular, scant and pale in color. Preganant women often abort; if the child is carried to term, it is small and appears to be poorly nourished. It takes women some time to recover from the puerperal state, and I have known some to have to remain in bed for a month or more. When this severe stage is reached, the patient is liable to die either of this disease, some complication, or an inter-current disease, the vitality and resisting power having been reduced to such a low state that it is hard for the system to fight any condition that may come up.

one

As to the number of worms present, in my experience, they have varied greatly. In my first case about thousand were counted, and possibly twice as many more passed unnoticed. In other cases, where the symptoms were just as severe, not, more than twenty or thirty could be found.

In the treatment of hookworm, we certainly have a specific; we know the cause, and it is easily recognized and understood by most all physicians, but still it is quite an undertaking because of the ignorance, poverty and carelessness of the majority of the subjects, the wide area covered, the enormous reproductive power of the worm, the lack of enforcement of sanitary laws in rural districts, and, what might be more effective, the lack of proper education of the people along this line.

After a careful observation of the

country surrounding the little village in which I am located, I have not been able to find more than one privy to every ten families, and not one of these properly constructed. In some localities the people use the chimney corner, stable, backyard, fence corners, and other convenient places for defecation. Until such practice as this is stopped, we may expect hookworm infection to continue.

How to check this is the question; but it seems to me that it should be done by enforcement of sanitary laws and by educating the population through the boards of health, medical inspectors, and sanitary officers. It is just as important for the counties and townships to have sanitary officers as it is for the cities. Our most efficient health department has already begun this most important step, and we hope that it will continue the good work until every hookworm district in the state has been thoroughly gone over, and every case treated, as the first and most important step is to treat as many cases as possible, thereby checking the supply of eggs at the source.

As to the direct treatment of the worms in the intestine, I have used thymol altogether. A great many other drugs have been advocated, but in my hands thymol has given such excellent results, I have used it in all my cases.

Before results can be had, the patient must be able to take the proper dose, and must be thoroughly prepared for the action of the drug. The heart and kidneys should always be examined, the kidneys especially, as thymol in large doses is a kidney irritant. The next thing is to thoroughly cleanse the intestines of mucus, as the worm is killed by the local action of the thymol, and if the worm is imbedded in a thick layer of mucus and chyme, the drug will pass through without producing the desired result. This is done the evening before the treatment is to be given by a large dose of Glauber salts, and only a glass of milk is allowed that evening for supper. The thymol is to be given in capsules early next morning on an empty

stomach, one dose every hour till three doses have been given. One or two hours after the last dose of thymol, another dose of salts is given to cleanse the intestines of the thymol, when the worms appear in the stools. In some instances I have been unable to get the patient to retain the last dose of salts, and in such cases I give a bottle of effervescent citrate of magnesia, which is easily retained. No food is allowed till the intestine has been cleared of the thymol.

As to the dose of thymol, I usually give from sixty to ninety grains to an adult at each treatment; in children the dose is regulated according to age. In one case I gave 120 grains before I could get results, due, I presume, to the large amount of mucus in the intestine. I have seen no more toxic symptoms produced from large doses than from small ones, and have seen large doses do the work, where small ones had failed.

Owing to toxic symptoms sometimes produced by thymol, it is better to have the patient remain in bed for several hours after the treatment. In my experience I have seen no more intoxication than vomiting or fainting, which passes off in a short while by keeping the patient in the recumbent position. These symptoms I have seen only a few times and were so mild as to require no treatment.

I repeat the treatment every one or two weeks till all the worms have been destroyed, which is determined by examination of the feces for eggs.

As to the number of treatments necessary, I have had to give from two to eight. Upon an average about three treatments, if properly given, will suffice.

As to results, about 75 per cent. of my cases have been cured; the remaining 25 per cent. have all been benefited, some failing to return for the second treatment, and others moving out of my jurisdiction. I have seen reinfection some months afterwards in several cases.

From a remunerative standpoint, have found the treatment of hookworm

I

disease a failure, as the compensation that I have received would do very little more than pay for the medicine used, but I feel that I have done just a little for suffering humanity and have extended to that class of indigent persons the aid and comfort which it has always been the privilege and pleasure of our profession to offer them.

A great deal of criticism has gone out from some of our hot-blooded Southerners to Mr. Rockefeller for his million dollar offer, but to my mind the hearts of the Southern people should flow with gratitude to him for his kind and generous offer, and if this sum is judiciously used, it will do a great deal toward the eradication of hookworm disease in the South. We also owe to Dr. Stiles, of Washington, and Dr. Harris, of Atlanta, a debt of gratitude for the light they have thrown on the subject. Coming to Our Own door, great credit should be given Dr. B. B. Bagby, of Virginia, who was one of the first to call the attention of the profession to hookworm in this state.

THERAPEUTIC NOTES. From New York Medical Journal, Dec. 13, 1913.

Treatment of Anal Fissure.-Roux, in Lyon médical for July 13, 1913, is stated, on the basis of eight cases treated by him, to approve strongly of a method first recommended by Lewis, of Brooklyn, which consists in applying to the fissure, held open for the purpose, a saturated solution of potassium permanganate. Sharp pain is induced, but this may be avoided or at least greatly lessened by previous application for a few minutes of a small tampon dipped in a two or three per cent. solution of cocaine hydrochloride. The application of permanganate solution is made daily. Cure results frequently in two or three days.

Treatment of Breast Lymphangitis in Nursing Women.-L. Dubrisay, in Journal de médecine de Paris for April 19, 1913, strongly recommends the repeated