PROTOZOA.

INTRODUCTION.

The aim of the present volume is to give an account of the animal parasites of man, the number of which is very large. The Protozoa that infest man are very important, and the literature relating to them and to the treatment of the diseases that they produce is very extensive. All that can be done in this Appendix is to give a very brief outline of some of the more recent and approved methods of treatment, for further details of which the reader should refer to standard medical works, among which the following are noteworthy:—

Allbutt and Rolleston (1907): “System of Medicine,” vol.ii, part 2, “Tropical Diseases and Animal Parasites,” London.

Castellani and Chalmers (1913): “Manual of Tropical Medicine” (second edition), London.

Laveran and Mesnil (1912): “Trypanosomes et Trypanosomiases” (second edition), Paris.

Manson (1914): “Tropical Diseases” (fifth edition), London.

Mense (1905): “Handbuch der Tropenkrankheiten,” Leipzig.

Ross (1911): “The Prevention of Malaria,” London.

Scheube (1910): “Die Krankheiten der Warmen LÄnder,” Jena.

References to the treatments tried in many parasitic diseases can be found in the Sleeping Sickness Bulletin and Kala-azar Bulletin, both now superseded and greatly extended in scope in the Tropical Diseases Bulletin, published by the Tropical Diseases Bureau, Imperial Institute, London, S.W.

The following diseases, due to protozoa and allied forms, are discussed:—

I.—AMŒBIC DYSENTERY.

Amoebic dysentery, due to Entamoeba histolytica (see pp.34–41), is present throughout the tropical world and also occurs in temperate zones.

Walker and Sellards429 (1913) conducted important experiments with amoebÆ on prisoners in the Philippine Islands. They showed experimentally that cultural amoebÆ are non-pathogenic. As regards experiments with Entamoeba coli, after feeding to twenty individuals they concluded that E. coli is a parasite of the human intestine but non-pathogenic and non-culturable. In a third series of experiments, after feeding with motile Entamoeba histolytica, tetragena cysts were found in the stools later; when tetragena cysts were administered, motile E. histolytica were present in the subsequent stools. Some of the histolytica cases developed dysentery after a time. They lay stress on the necessity for the frequent examination of stools in order to detect carriers. The incubation period of entamoebic dysentery is usually long.

With regard to the symptomatology of amoebic dysentery, Castellani and Chalmers distinguish four types—the acute, chronic, latent, and mixed types.

The acute type has an abrupt onset; pain is felt in the lower part of the abdomen, and the motions, rarely exceeding thirty daily, are accompanied by much griping and straining. Blood and mucus are present in the motions, and occasionally greyish material, consisting of leucocytes, mucus, Charcot-Leyden crystals, amoebÆ, and bacteria, sometimes with particles of tissue. Nausea and vomiting may occur. Digestion is usually deranged. The abdomen is sunken, the liver and spleen are normal, but tenderness is felt along the course of the large intestine. The urine may be diminished in quantity.

The chronic type may succeed the acute, or appear like diarrhoea, the motions being fÆculent and containing mucus. Between exacerbations, constipation may occur. The number of motions may only be twelve to fourteen per diem. Gangrenous complications may occur at any time, and chronic dysentery may persist for many years.

The latent type is important, as the patients, though free from dysenteric symptoms, harbour amoebÆ and act as parasite carriers. The latent condition may lead to acute attacks or to liver abscess.

The mixed type occurs where amoebic and bacillary dysentery are combined. There is much fever, nausea, and vomiting. The motions are numerous and often very offensive.

Treatment.—The most modern method of treatment, due to Leonard Rogers, is by emetine. According to Castellani and Chalmers, it is well to relieve griping and straining by either a hypodermic injection of morphia or by small enemata of 40 minims of laudanum in 1oz. of mucilage of starch or by using 1/4gr. morphia or 1/4gr. codeine suppository. A dose of castor oil (?iv to ?vi) with or without a few minims of liquor opii sedativus or a few doses of saline may be given during the first twenty-four hours. After the castor oil has acted or simultaneously, emetine treatment should be commenced; 1/3 to 1/2gr. of emetine hydrochloride, dissolved in sterile normal salt solution, is injected hypodermically three times a day for two or three days.

If emetine cannot be obtained, 5gr. doses of ipecacuanha every three to six hours in the form of membroids, or as pills coated with salol or keratin, can be substituted.

After acute symptoms have disappeared, intestinal irrigations once or twice daily, on alternate days, are useful. A solution of tannic acid (3 to 5 per 1,000) or of quinine bihydrochloride varying in strength from 1 in 5,000 to 1 in 750 is very slowly injected in quantities of 1/2 to 3 pints by means of a long, soft, rectal tube.

For gangrenous dysentery Castellani and Chalmers state that appendicostomy, with irrigation of the whole lower bowel with quinine lotion (1 in 1,000) or collargol (1 in 500), is the only chance.

The use of emetine should be continued in smaller doses after the dysenteric symptoms have ceased, in order to prevent relapses and as a possible safeguard against the development of a liver abscess.

Recently (July, 1914), Dr. W.E. Deeks430 has given an account of his successful procedure in dealing with the dysenteries in the Ancon Hospital, Panama Canal Zone, of which medical clinic he is the chief. With regard to amoebic dysentery he advocates: (1) Rest, to increase the patient’s resistance; (2) a generous milk diet, which is practically all absorbed before it reaches the large bowel; (3) saline or plain water irrigations, one to three daily; (4) the administration of bismuth sub-nitrate in heroic doses; 180gr. is given mechanically suspended in about a tumbler of plain or effervescent water every three hours, day and night in severe cases, only lessening the amount when improvement takes place. Mechanical suspension in a large quantity of water is essential. When the stools begin to decrease in number and the tongue becomes clean, the number of doses is reduced to three or four daily. In very chronic cases one or two doses daily for a month after convalescence are recommended.

In exceptional cases of extreme emaciation and exhaustion, showing marked toxic symptoms, surgical treatment is necessary, and at Ancon a wide, open cÆcostomy is performed.

The treatment of dysentery with bismuth sub-nitrate has been in use for some years at Ancon. Latterly, a combined treatment by hypodermic injections of emetine and bismuth sub-nitrate by the mouth has been used, and the authorities there consider that it is better to combine the two drugs rather than use each singly. Emetine probably acts as a direct poison to the amoebÆ, while the bismuth probably acts by destroying the symbiotic organisms necessary for their growth.

With regard to preventive measures, all drinking water should be filtered and boiled, and uncooked vegetables and salads avoided. Scrupulous care with regard to personal cleanliness, and avoidance of touching the mouth or lips after contact with dysenteric patients, are essential. Isolation of parasite carriers is of great use in combating and controlling outbreaks of amoebic dysentery. The pollution of soil and water must be rigorously prevented.

Liver abscess due to amoebÆ must be localized by exploratory punctures, and then opened and drained. Intramuscular injections of emetine hydrochloride, 1/6gr. to 1/2gr. every day, will reduce the temperature and afford relief.

Oral endamoebiasis has been recently investigated by Bass and Johns, Smith and Barrett and colleagues (see pp.43, 733). It responds to treatment with emetine, and 1/2gr. of emetine hydrochloride administered hypodermically each day is of service. Rinsing the mouth with a solution of fluid extract of ipecacuanha is also useful.

Rogers431 (1915) recommends a combined treatment of emetine and streptococcal vaccines for pyorrhoea alveolaris.

II.—TRYPANOSOMIASES.

The human trypanosomiases are those occurring in Africa, due to Trypanosoma gambiense and T. rhodesiense and spread by GlossinÆ, and that due to T. cruzi, occurring in South America and spread by the Reduviid bugs, Triatoma spp. These trypanosomiases present different clinical features and are best dealt with separately.

African Sleeping Sickness.

Sleeping sickness, due to Trypanosoma gambiense or varieties thereof, was first reported from West Africa and is now present, not only along the West Coast and in Nigeria, but throughout the Congo basin into Uganda, north of which it exists in the Bahr-el-Ghazal province of the Sudan. In Nyasaland and Rhodesia a more virulent but less widely distributed disease is produced by Trypanosoma rhodesiense.

There is a general similarity between the two diseases, and the symptoms as described by the leading authorities agree in the main. The malady due to T. rhodesiense has been known only since 1910 and the differences between the malady due to it and to T. gambiense will be indicated.

The course of the disease may be roughly divided into three stages, the incubation, the febrile or glandular, and the cerebral stage.

The exact incubation period is not known with certainty in man. Probably, in most cases, it does not exceed two to three weeks, but disease signs may not appear for months. The bite of the Glossina gives rise to local irritation, which may be overlooked. The irritation usually subsides in the course of a few days.

The febrile, or glandular stage, is marked by attacks of fever of an intermittent type. An erythematous eruption is often found on Europeans. This rash begins as irregularly shaped pinkish patches which clear in the centre until a ring is produced. It may occur on any part of the body but is more frequent on the trunk. A typical symptom is the enlargement of one or more of the lymphatic glands, especially those of the neck. A general, deep hyperÆsthesia, known as Kerandel’s sign, may be present, and if the patient strikes a limb against any hard object, a feeling of acute pain is felt, the sensation being slightly delayed. As repeated attacks of fever increase, the patient may become anÆmic. The febrile stage may last for years, and cure may be brought about at this phase, but frequently, after the febrile stage has lasted some time, the cerebral stage is reached. Tachycardia is also a symptom. Auto-agglutination of the red blood corpuscles is another useful characteristic, as it is said to occur rarely in other tropical diseases, but some workers doubt its value.

The cerebral, or true sleeping sickness stage is marked by a great change in the habits of the victim, who becomes apathetic and dull, careless and dirty in habits, and begins to experience difficulty in walking. Tremors of varying degrees of severity are common and the gait is peculiar. There is usually fever with rise of temperature from 100°F. to 104°F. in the evening, becoming subnormal in the morning. For some days before death, it often becomes permanently subnormal. Congestion and oedema of the lungs, with patches of pneumonia, are not infrequently observed before death. The torpor gradually deepens, and the patient loses flesh. Frequently the lips swell and saliva dribbles. The patient usually becomes comatose and death ensues. Mania and delusions, and psychical and physical symptoms resembling those found in general paralysis of the insane, sometimes occur, and death may arise from secondary complications such as pneumonia or dysentery.

Pathologically, the disease seems to consist of a chronic inflammation of the lymphatic system. The trypanosomes reach the lymphatic glands which become inflamed, and gradually invade the blood and the cerebrospinal fluid. Sooner or later, as a result of the lymphatic disease, changes occur in the membranes and substances of the brain and spinal cord. There is round-celled perivascular infiltration of the pia-arachnoid of the brain and spinal cord. These changes cause compression of the blood-vessels, and so lessen the supply of blood to the brain and spinal cord. Further changes in the latter organs result in the production of the symptoms that have given the disease the name of “sleeping sickness.”

The disease due to Trypanosoma rhodesiense generally runs a more rapid course than that due to T. gambiense. The torpor and sleepiness may not be obvious or be very slight, and the enlargement of the lymphatic glands of the neck also may not be marked or may appear to be absent. The duration of the disease often appears to be from three to six months.

Treatment is only of use if commenced in the earlier stages of the disease. The substances of most value so far are arsenic in the form of atoxyl (introduced by Wolferstan Thomas in 1905) and antimony in the form of tartar emetic. Castellani and Chalmers and Manson recommend treatment by combining the use of both substances. The combined treatment is recommended not only because both substances have been proved of service independently, but also because certain strains of trypanosomes resistant to arsenic are known, and trypanosomes can develop a resistance to arsenic. Such forms, that would not be affected by the atoxyl, are left open to attack by the antimony salt. Daniels also recommends combined arsenic and antimony treatment, and (1915) uses atoxyl and antiluetin.

Atoxyl is best given intramuscularly in 10 per cent. solution in sterile normal saline solution. Galyl is also said to have given good results.

Castellani and Chalmers recommend: (1) Manson’s method of administration of atoxyl, viz., 2 to 3gr. of atoxyl are given by intramuscular injection every third day for at least two years; or (2) Broden and Rodhain’s method, 7 1/2gr. of atoxyl by intramuscular injection every fifth day. For the combined therapy by atoxyl and antimony they recommend the following:—“An atoxyl injection (3gr.) is given every third day or 7 1/2gr. every fifth day, and sodiotartrate of antimony (Plimmer’s salt) is administered daily, 2gr. dissolved in a large quantity of water (2 pints) by the mouth or by the rectum. Tartar emetic, however, is best given by intravenous injections, using solutions of 1 in 100 or 1 in 1,000. The dose of the drug to be given is 5 to 10 cg. per injection. It is important that none of the fluid of the injection should escape into the surrounding tissues, as a violent inflammation may result. These injections should be administered monthly on ten consecutive days for a long period.”

Macfie and Gallagher (1914) injected 6gr. of atoxyl intramuscularly every week in cases infected with T. nigeriense in the Eket district of Southern Nigeria.

Large doses of atoxyl were often said to cause distressing results such as optic atrophy, and when the onset of such occurred the drug was usually discontinued. However, Daniels432 (July, 1915) points out that eye troubles, such as iridocyclitis, are symptoms of trypanosomiasis.

Other arsenical preparations such as soamin and arsenophenylglycin have been used, but less successfully than atoxyl. Fowler’s solution, well diluted, has been given by the mouth when treatment by injection was not possible, the doses commencing with 5 minims and increasing to 15 minims.

Salvarsan and neo-salvarsan have also been tried for sleeping sickness. Plimmer recommended powdered antimony suspended in sterile olive oil. Ranken used precipitated metallic antimony in normal saline solution injected intravenously.

Laveran and Thiroux have recommended a combined treatment of atoxyl and an inorganic salt of arsenic such as orpiment. The orpiment is given as pills, in doses of 2gr. of orpiment two or three times daily. Opium is added to the orpiment to prevent diarrhoea. This treatment is said to have been used in man with good results.

Trypanosoma rhodesiense seems less amenable to treatment than T. gambiense.

The main preventive measures seem to lie in segregation of the sick in areas not infested with GlossinÆ, and in measures against these flies, such as bush clearing and destruction, to some extent, of proved reservoirs in big game.

South American Trypanosomiasis.

The chief clinical features of the trypanosomiasis occurring in Brazil have already been indicated (see p.87). With regard to treatment, according to Castellani and Chalmers the indications are the same as those for African trypanosomiasis, together with treatment for hypothyroidism. Preventive measures are directed against the Reduviid bug, Triatoma megista, that transmits the disease. The bugs occur in numbers in the cracks of the houses of the poor of Minas Geraes, and may be destroyed by sulphur fumigation, lime-washing or whitewashing.

III.—FLAGELLATE DIARRHŒA AND DYSENTERY.

The chief causal agents are Trichomonas hominis (T. intestinalis), Chilomastix (Tetramitus) mesnili and allied organisms (see pp.54 to 57), and Lamblia intestinalis (see pp.57 to 60 and Appendix pp.734 to 736).

These parasites and the associated diarrhoeas occur in temperate as well as in warm climates. Probably some of the diarrhoeas in India are thus caused. The same, or similar parasites occur in various MuridÆ, especially rats and mice, which may act as reservoirs.

(i) Mello-Leitao433 (1913), writing from Rio de Janeiro, states that there is a primary flagellate dysentery, due to Trichomonas intestinalis (Leuckart) and to Lamblia intestinalis (Lambl), either separately or in combination. He considers it a benign disease, and the most frequent form of dysentery in young children. Trichomonas and Lamblia were found to be pathogenic to children under 3 years of age.

Escomel434 (1913) collected 152 cases of dysentery in Peru due solely to Trichomonas. Examination of the reservoirs containing the water used for drinking purposes showed the presence of Trichomonas. After the reservoirs were cleaned no more Trichomonas was found and the cases of dysentery ceased.

Brumpt435 (1912) described a colitis due to Trichomonas intestinalis in a patient returned from Tonkin.

Cases of infection by Chilomastix (Tetramitus) mesnili, with colitis or dysenteric symptoms, are recorded by Brumpt (1912) from France, and by Nattan-Larrier436 (1912) from the Ivory Coast respectively.

Marques da Cunha and Torres437 (1914) describe five cases of chronic diarrhoea in Brazilian children due to the Chilomastix (Tetramitus).

GÄbel438 (1914) described a case of seasonal diarrhoea contracted in Tunis and caused by a Tetramitid parasite which he named DifÄmus tunensis, as the discoverer considered that it lacked an undulating membrane in its large cytostome.

Derrieu and Raynaud439 (1914) record a case of chronic dysentery in Algeria due to a Trichomonad possessing an undulating membrane and five free flagella. The parasite was named Hexamastix ardindelteili, but the generic name Hexamastix is pre-occupied. Chatterjee’s Pentatrichomonas bengalensis (1915) is possibly the same organism.

Treatment.—Escomel (1913), finding ipecacuanha and calomel useless, recommends turpentine for Trichomonad dysentery. Two to 4gr of essence of turpentine in an emulsion are given by the mouth, and enemata containing 15 to 20 drops of turpentine emulsified in the yolk of an egg to which is added a little water and tincture of opium. Derrieu and Raynaud found this treatment effective in Algeria. Smithies440 (1912) reports two cures of cases of severe dyspepsia, in which Trichomonads were found in the stomach contents, after administration of a single dose of 50 to 60gr. of thymol, given at bed-time, together with 2gr. of calomel, and followed by an ounce of Carlsbad salts in the morning. The patients came from the Southern United States, and had been in the habit of drinking unfiltered surface water in the localities in which they lived. Mello-Leitao441 used magnesium sulphate and water or milk diet. Sometimes enemata of collargol (1 per cent.) or electrargol were required. Rosenfeld recommended calomel. Methylene blue has also been tried. Recently, Escomel442 (1914) recommends enemata of an aqueous solution of iodine (1 per 1,000) and farinaceous diet. Lynch443 (1915), working in South Carolina, recommends a mouth wash of saturated solution of bicarbonate of soda three times daily in oral infections. A similar solution was used as a douche in vaginal trichomoniasis.

Stiles (1913) points out that when amoebÆ or flagellates are found in a large percentage (10 to 40, or even 60) of the members of a community, means should be taken to improve the methods for the disposal of the dejecta, so that the food supply may be carefully protected against fÆcal contamination. Cysts of the parasites may be air-borne or conveyed to food on the bodies of house-flies.

(ii) Lamblia intestinalis in man may cause diarrhoea with dysenteriform stools. The diarrhoea may be of a chronic recurrent character. The flagellate, or a variety of it, is fairly common in the digestive tract of rats and mice.

Mathis444 (1914) gives an interesting account of cases in Tonkin. In a child, aged 3, the stools were at first glairy and blood-stained, containing many encysted Lamblia. The child’s home was infested with mice. In another case, the house of the patient harboured numerous rats.

According to Mathis, prognosis is favourable, but emetine hydrochloride is without action on Lamblia. Prowazek and Werner445 (1914), however, state that emetine will act upon the flagellates, but not upon the cysts. They recommend uzara (two tablets, three times daily) and extract of male fern as useful in certain cases. Martin Mayer (1914) found emetine hydrochloride successful in a case in the Hamburg Seamen’s Hospital, but Assmy (1914) points out that a suitable diet and daily doses of magnesium sulphate are sufficient, in his experience, to effect an improvement, and he doubts the specific action of emetine. Escomel (1914) recommends milk diet, then calomel succeeded by castor oil.

According to Noc, Lamblia may also be water-borne. Healthy carriers of Lamblia cysts are known. Food should be protected from being soiled by rats and mice.

IV.—LEISHMANIASES.

A. Kala-azar.

(i) “Indian” Kala-azar due to Leishmania donovani.

Indian kala-azar due to Leishmania donovani is a very fatal disease with a rate of mortality varying from 70 to 98 per cent. of the cases.

The incubation period is very variable and the early symptoms not well defined. The incubation period seems to range from three weeks to several months after exposure to infection. The onset seems to commence with a rigor and attack of irregular, remittent fever, which may show two remissions per day in a four-hourly temperature chart. Rogers considers the daily double remission almost diagnostic. The duration of this first attack is from two to six weeks. The spleen and liver enlarge, especially the former, and are painful and tender. Towards the end of the time the temperature declines and the first period of the disease ends. After this period an apyrexial interval occurs, which, after some weeks, ends in an attack of fever resembling the first. Periods of pyrexia and apyrexia alternate. AnÆmia commences and asthenia appears and deepens steadily. The patient is now thin and wasted, the abdomen much swollen and protuberant, the ribs show clearly, the limbs are wasted and skin and tongue darker than normal. In Europeans the skin is of a remarkable earthy hue, and in natives of India darker than normal, approaching black. Intestinal disturbances, often in the form of very obstinate and intractable diarrhoea or dysenteric attacks, are common. Papular eruptions often appear, particularly on the thighs; hÆmorrhages also may occur. The disease lasts for periods varying from seven months to two years, and usually ends fatally.

Treatment, unfortunately, has not been very successful up to 1915. Manson has reported two cases of cure by intramuscular injections of atoxyl daily or every other day in doses of 3gr. Rogers has advocated large doses of quinine, 60 to 90gr. daily until the temperature falls and then 20gr. daily. Castellani and Chalmers consider the best results are obtained by large doses of quinine given intramuscularly, supplemented by a course of quinine cacodylate injections or atoxyl injections. Tartar emetic should be tried (see pp.627, 629), especially as L. Rogers (July, 1915) has had promising results in ten cases. Castellani (1914) and Mackie (1915), have also had successful results. Leishman states that the administration of red bone-marrow, either raw or in the form of tablets, may be beneficial. Good nursing and careful diet are essential, and diarrhoea or dysentery must receive the appropriate treatment.

With regard to preventive measures, the extermination of bugs and other biting insects seems to be of most service. Domestic and personal cleanliness is of great importance. Patients should be segregated. It would probably be as well if houses in which many cases of kala-azar occurred were destroyed. Dodds Price, in Assam tea gardens, moves the coolie lines 300 to 800 yards from old infected ones, with satisfactory results.

(ii) Infantile Kala-azar due to Leishmania infantum.

This malady is found among children, rarely in adults, along the Mediterranean littoral.

The disease commences insidiously and is often unrecognized until some intestinal disturbance occurs. The spleen is then found to be somewhat enlarged, and the case has often been regarded as one of malaria. The child becomes anÆmic, suffers from diarrhoea, alternating with constipation, and has attacks of irregular fever. The spleen continues to enlarge and protrudes from under the cover of the ribs. HÆmorrhages from the nose and gums and into the skin occur. AnÆmia and wasting set in. The abdomen then becomes very enlarged. The child becomes much less active both physically and mentally, and looks prematurely old. Death often occurs from exhaustion, though some cases of spontaneous recovery are known.

Treatment up till recently has been unsatisfactory. Some of the remedies tried, as quoted by Castellani and Chalmers, are 15 cg. doses of atoxyl, benzoate of mercury (2 to 4mg. as a daily injection), thiarsol (5 to 15mg. by subcutaneous injection), salvarsan, etc. Recently Cristina and Caronia (1915)446 have given repeated intravenous injections of 1 per cent. aqueous solution of tartar emetic, the dose varying from 2 to 10 cg. The treatment in various cases has lasted from 15 to 40 days.

Prophylactic measures seem to lie in the destruction of infected dogs and diminishing the breeding of fleas (see p.111).

B. Oriental Sore, due to Leishmania tropica.

Oriental sore, known under many other names (see p.107), is a local infection of the skin due to Leishmania tropica. The incubation period varies from a few days to some weeks, or even months, and then one or several small itching papules appear. Each spot becomes red and shotty, the papules increase slowly in size and the surface becomes covered with papery scales. After a variable time, usually not exceeding three to four months, ulceration occurs and a yellowish secretion is exuded that soon dries into a scab. Under the scab ulceration continues by erosion of the edges, and subsidiary sores arise around the parent ulcer and usually fuse with it. Healing commences after six to twelve months. Granulation begins at the centre and spreads outwards, and when healing is complete, a depressed, whitish or pinkish scar remains.

Many treatments for Oriental sore have been devised but do not seem particularly satisfactory. Castellani and Chalmers state that the scabs should be removed by boracic acid fomentations, and the ulcers thoroughly disinfected once or twice daily with a 1 per 1,000 solution of perchloride of mercury, after which an ordinary antiseptic ointment is applied.

The use of permanganate of potash has been advocated both by French and English doctors. Both large and small sores can be treated. The patient’s skin around the sore is protected by a thick layer of vaseline, and the surface of the ulcer powdered with potassium permanganate, which is kept in position by a pad of gauze and a bandage. The treatment is said to cause great pain for six to eight hours, but at the most, three treatments are necessary before the sore becomes a simple ulcer, well on the way to healing. The permanganate may also be used in ointment. Excision of the ulcer when small is advisable when the site of the ulcer permits of this. According to Manson, reports on treatment by radium, salvarsan and carbon dioxide snow are decidedly promising. Mitchell (1914)447 reports favourably on the use of carbon dioxide snow in the form of a pencil, in India. In Brazil several workers (1914) record successful results from the intravenous injection of a 1 per cent. solution of tartar emetic in distilled water. Low (1915) has successfully treated a case by direct local application of tartar emetic. Row (1912) has treated cases of Oriental sore by inoculation of killed cultures of the causal organism.

As the disease is very contagious, the slightest wound, and any insect bite, should be thoroughly disinfected with 5 per cent. carbolic acid or iodine. Destruction of bugs, lice, and other biting insects should be enforced. As dogs may contract the disease (see p.108), it is well not to allow them in the house and not to encourage undue contact with them.

Naso-oral Leishmaniasis (Espundia) due to Leishmania tropica.

This form of Leishmaniasis has been reported from South America and recently by Christopherson448 (1914) from the Sudan. In South America it is often called Espundia, also Buba and Forestal Leishmaniasis. The primary lesion is found usually on the forearms, legs, chest or trunk. This ulcer is of the Oriental sore type, and after some months, or even as long as two years, heals up, leaving a thick scar. While the ulcer is open, or more often after it has healed, lesions appear on the mucosa of the mouth and nose. The hard and soft palate, gums and lips all may be attacked. The mucosa of the nose is usually attacked and the cartilages become destroyed, producing great deformity. In bad cases the pharynx and larynx may become infected.

Till recently it was believed that treatment was of little use unless the case could be investigated early. Escomel considered that if the primary cutaneous lesion was excised or destroyed, further progress of the disease was prevented. When lesions have appeared on the mucosa of the mouth or nose, little could be done. The ulcers might be cauterized and mild antiseptic mouth washes used.

In 1913 Vianna, working in Brazil, introduced treatment by tartar emetic, which is now becoming more widely known and proving efficacious. Carini449 (1914) applies it thus. Tartar emetic (that is, potassium antimonyl tartrate) in 1 per cent. aqueous solution is introduced slowly into a vein, such as the vein at the bend of the elbow, in doses of 5 to 10c.c. daily or on alternate days according to the tolerance of the patient to the drug. Eighteen to forty injections have been used. In some of the memoirs on the subject, the drug is referred to as antimony tartrate.

The course of the disease is chronic and may last for twenty to thirty years, death usually resulting from some intercurrent disease.

At present the actual transmitter of Espundia is not known with certainty. Various sand-flies (SimulidÆ) have been suspected of transmitting the disease, though so far proof is wanting. It has also been suggested that the natural food sources of some SimulidÆ known to bite man, namely, certain snakes450 and lizards,451 are possible reservoirs of the disease.

Prophylactic measures would seem to consist in the immediate disinfection of insect bites by tincture of iodine, and by avoidance of areas known to be infested with snakes and lizards, and insects that prey on them and man indifferently. The destruction of the primary lesion as soon as detected is essential, and the isolation of advanced cases of the disease seems advisable.

V.—SPIROCHÆTOSES.

A. Relapsing Fevers.

The relapsing fevers of Europe and of America, due to SpirochÆta recurrentis and S. novyi (probably a race of S. recurrentis), present much the same symptoms, which differ in some respects from those due to S. duttoni, the excitant of “tick” or “relapsing” fever in Africa (see pp.116–122).

The incubation period of S. recurrentis varies from two to twelve days, during which time a very slight indisposition may be noticed. The onset is usually sudden, with severe headache, pains in the back, limbs and stomach and a feeling of weakness. There is a rise of temperature to 103°F. or 104°F., and the temperature continues high till about the sixth or seventh day. The skin is yellowish, hot and damp; a rash, disappearing on pressure, may occur on the trunk and legs, nausea is always present and thirst is usual. The liver and spleen both enlarge. The number of respirations and pulse-rate become increased. On the sixth or seventh day a crisis occurs. There is violent perspiration, with a rapid fall of temperature, pulse and respiration become normal and the patient sleeps and awakes better. Improvement continues for some days, and recovery may ensue, but usually about the fourteenth day relapse occurs, lasting usually three or four days. A second relapse is unusual. Numerous complications are known, e.g., bronchitis, pneumonia, diarrhoea and dysentery.

With regard to treatment, the specific appears to be salvarsan. Castellani and Chalmers recommend salvarsan administered intravenously. Intramuscular inoculations (for example, into the buttock) of a suspension of “606” in oil can also be given. The drug is very efficacious, but large doses should not be given. An intravenous injection of 4 or 5gr. does not give rise to unpleasant symptoms but is sufficient to effect a cure.

The incubation period for the American form of the disease is at least five to seven days, and the first attack lasts about five to six days. The treatment is by salvarsan as detailed previously.

As relapsing fever is spread by body lice and possibly by bugs, preventive measures are directed against these insects. Strict cleanliness of person, clothing, bedding and dwellings is essential. Furniture, e.g., wooden bedsteads, liable to harbour such insects should not be used.

The principal and best-known relapsing fever of Africa is that excited by SpirochÆta duttoni, and transmitted to man by ticks, chiefly Ornithodorus moubata. The incubation period is usually about seven days but may be longer. The patient is dull and lethargic, perspires freely and is often constipated. The temperature rises to 103°F. or 105°F., there is headache, pains in the back and limbs, general chilliness and great pain in the region of the spleen, which often enlarges. The symptoms become worse, there is a fall of temperature with improvement in the morning, and a rise, with increase of pain, in the evening. SpirochÆtes are now found in the blood in greater numbers. The symptoms last three to four days and end in a crisis with profuse sweating and fall of temperature below normal. The day before the crisis there is a pseudo-crisis, when the temperature falls but there is no improvement. The patient is left weak and tired. Recovery may follow, but more usually a relapse occurs. The intermission period varies; five to eight days is common. The symptoms of the relapses are like those of the first attack. The number of relapses varies, five to eleven may occur.

The treatment recommended is by salvarsan, as for the European relapsing fever.

With regard to prophylaxis, localities where ticks abound must be avoided and the parasites themselves destroyed. Native huts should be avoided. Mosquito nets, a bed well off the ground and the use of night lights are advised by Manson to avoid attacks by ticks, which are often nocturnal in their habits.

In North Africa (Algeria, Tunis, Tripoli, Egypt), and sometimes in the Anglo-Egyptian Sudan, a spirochÆtosis due to S. berbera occurs. According to Castellani and Chalmers, the incubation period varies somewhat. The fever reaches its height during the first twenty-four hours, and afterwards shows a morning remission. Jaundice is often absent, but there may be hepatic tenderness and splenic enlargement. One or two relapses usually occur. The treatment is on the same lines as for the other spirochÆtal fevers. Sergent and Gillot452 (1911), working at the Institut Pasteur of Algeria, have had good results by using injections of salvarsan in doses of 0·75 to 1·0 cg. per kilogramme weight of the patient. The prophylactic measures are directed against lice and other biting insects. Personal cleanliness is most necessary.

In Asia, a relapsing fever, due to the spirochÆte named S. carteri by Manson in 1907, producing a mortality of about 18 per cent., occurs. The symptoms have a general resemblance to those produced by S. recurrentis, but on the fall of temperature to subnormal on the sixth or seventh day, when profuse perspiration and polyuria occur, instead of improvement following, the patient often becomes collapsed, with a clammy skin and feeble pulse. Improvement is slow. The first relapse occurs about the fourteenth day of the attack, when the temperature may be higher than for the first attack. There are seldom more than four relapses. The treatment is by salvarsan, of which doses of not more than 5gr. intravenously should be given. Sudden heart failure being common, Castellani and Chalmers state that cardiac stimulants should be given. Prophylaxis is the same as for European relapsing fever.

B. Yaws or Framboesia tropica.

Yaws is essentially a tropical disease, though it is found in the tropical and subtropical zones in all parts of the world, except in the mountains and cold districts. In 1905, Castellani found the causal organism, Treponema pertenue (sometimes called SpirochÆta pertennis) (see p.127). The disease shows three periods: (1) The primary stage, consisting of the development of the primary lesion or papule, which is usually extragenital. The papule dries into a crust beneath which an ulcer lies. (2) The secondary or granulomatous stage, which commences from one to three months after the primary lesion is first seen. It consists of a general eruption of small papules, some of which enlarge and become granulomatous nodules covered with a yellowish crust. They are common on the limbs and face. (3) The tertiary stage, in which deep ulcerations and gummatous nodules appear. Any of the tissues may be involved. Osseous lesions may occur. The disease does not appear to be hereditary; it is usually spread by contact.

The best treatment appears to be by salvarsan or neo-salvarsan. Castellani and Chalmers recommend intramuscular and intravenous injections. For intramuscular injection an alkaline or neutral solution of the drug is preferable, or a suspension of the drug in oil may be used. The dose varies from 0·3 to 0·5gr according to the age and sex of the patient. For use intravenously, a slightly smaller dose is required. Galyl is also being used.

In countries where framboesia is endemic, slight skin abrasions should be carefully treated with antiseptics. Yaws patients should be isolated till cured, and their dwellings and personal possessions disinfected.

C. Syphilis.

Syphilis, due to Treponema pallidum (sometimes called SpirochÆta pallida), is prevalent throughout the tropics as well as in temperate zones. The disease is amenable to treatment by salvarsan and neo-salvarsan, for administration of which see relapsing fever and yaws. Galyl is also being used with favourable results. Lambkin’s mercury cream has been found useful in treating numerous cases in Uganda. The life-history of the parasite is given on p.124, and further medical details hardly come within the purview of this book.

D. Bronchial SpirochÆtosis.

Bronchial spirochÆtosis, due to SpirochÆta bronchialis (see pp.122, 739) is probably of wide distribution in the tropics. The spirochÆtes have been found in cases of chest complaints, especially those with bronchitic symptoms. The disease may be suspected in atypical cases of pneumonia and bronchitis, and may be mistaken for incipient phthisis.

Chalmers and O’Farrell453 (1913), writing from Khartoum, recommended rest in bed, good food and ventilation, coupled with treatment by arsenic in some form, preferably associated with glycerophosphates. These may be given by the mouth, or intramuscularly as an injection of:—

Taylor454 (1913–14), writing from Entebbe, Uganda, prescribes arsenious acid by the mouth in increasing doses. Creosote has been used in West Africa.

VI.—MALARIA.

Malaria, known also under the names of ague, paludism, marsh fever, remittent fever, intermittent fever and climatic fever, among others, is a very widely spread disease. It is most prevalent in the equatorial regions and gradually diminishes north and south of the equator. The various malarial parasites (see pp.155 to 172) are spread by species of Anophelines, and hence malaria is present in districts favourable to these intermediate hosts, that is, in places where there is a considerable amount of atmospheric moisture and rain, as well as heat.

The principal malarial parasites are: Plasmodium vivax, the agent of simple tertian fever; Plasmodium malariÆ, the parasite of quartan malaria, and Laverania malariÆ or Plasmodium falciparum, producing malignant tertian or sub-tertian malaria (and quotidian, see p.167). These various malarial fevers present certain clinical features in common, which will be stated here (see also pp.155 to 157). For further particulars regarding malaria in all its aspects the reader is referred to the book by Sir Ronald Ross on “The Prevention of Malaria,” to the “Manual of Tropical Medicine,” by Drs. Castellani and Chalmers, and to the “Tropical Diseases” of Sir Patrick Manson.

Typical malarial fevers consist of a series of pyrexial attacks which recur at definite intervals of twenty-four (quotidian), forty-eight or seventy-two hours, according to the parasite present in the patient’s blood. Each attack shows three stages, a stage of rigor, a heat stage and a stage of profuse perspiration. Following on these three stages, there is an interval relatively or actually without pyrexia. Then the fever returns again. A rise of temperature, often accompanied by a general feeling of malaise, may precede the initial stage of rigor. When the latter sets in, the patient feels intensely cold, shivers violently, the skin becomes cold and the features pinched. There may be violent vomiting and convulsive attacks in young children. The temperature, however, is really above the normal, and continues to rise. After about an hour, the shivering abates and the heat stage succeeds it. The temperature rises rapidly, even to 106°F. The patient becomes very flushed, the pulse is rapid, headache may be intense and the skin dry and burning. This stage, that causes acute distress to the patient, may last for one or often three to four hours, and then the patient commences to perspire profusely, the clothing and bedding often being saturated with sweat. After this, the fever rapidly declines, and when the sweating ceases, the patient may feel almost well although somewhat languid. The sweating stage persists from two to four hours, so that the attack lasts as a rule from six to ten hours. After an interval of one, two or three days, a recurrence takes place. During the early part of the attack, especially at the stage of rigor, there is great splenic enlargement. At first the enlargement disappears in the interval, but in the case of repeated attacks the spleen tends to become permanently enlarged. During malarial attacks and during the intermission period, there is a great increase in the amount of nitrogen excreted by the kidneys, while the excretion of iron and bile in the fÆces is increased.

Stitt455 (1914) points out that it is characteristic of malignant tertian paroxysms that they set in with chilly sensations rather than a frank, definite chill, and that the fever is of the remittent type.

Plasmodium malariÆ and P. vivax rarely produce marked lesions in the bodies of their hosts, as they sporulate in the circulating blood and so do not accumulate in any one organ. On the other hand, Laverania malariÆ (Plasmodium falciparum) multiplies within the internal organs of its host, and consequently aggregates or clusters of the parasites occur therein. The organ in which most sporulation occurs suffers most. The liver is generally enlarged, soft and congested. The capsule of the spleen is tense, but the splenic consistency is less than normal. The bone-marrow is often dark and congested in the spongy bones and brownish-red in long bones. The blood-capillaries of the brain and spinal cord are often filled or blocked with sporulating parasites and large quantities of pigment are found in these organs. Even if the parasites are absent, the pigment is present in the endothelial cells. Pigment is found in most organs of the body.

Atypical forms of malaria may occur in which some or all of the symptoms are much modified. Irregular fevers also may be produced by successive infections by the same parasite, or by the presence of two different malarial parasites.

As regards the diagnosis of malaria, according to Manson the three pathognomonic signs are—periodicity, the effect of quinine, and the presence of the malarial parasite.

Treatment.—The great specific for malaria is quinine. It attacks the merozoites or asexual generation. The drug can be administered by the mouth, by the rectum, by intramuscular injections or by intravenous injections, the two latter methods being adopted in serious infections or where gastric complications are present. When quinine is taken by the mouth, the more soluble acid salts, e.g., quinine bihydrochloride and bisulphate, are better than the sulphate, the form in which quinine is usually sold. Tablets, pills and capsules are convenient means of taking quinine but must not be old or hard, or they may pass unchanged through the body. In the case of mild tertian or quartan malaria, Castellani and Chalmers recommend the administration of a dose of quinine four hours before the sporulation of the parasite is due. Another modification is to give 10gr. of quinine by the mouth in the morning and a second dose of 10gr. as above. In many cases they give 5 to 10gr. of the drug three times a day. Administration of quinine per rectum may be useful but they recommend intramuscular inoculation. The solutions used must be sterile, and the “sterilettes,” small, hermetically sealed vials, containing 1grm.) or 1/2grm. (7 1/2grm.) of quinine in solution, are recommended. A deep injection into the deltoid or gluteus muscle is usual.

For pernicious infections, intravenous inoculation with not less than 1grm. at a time is recommended.

After the fever has subsided, the administration of quinine in smaller doses must be continued for some time, in order to avoid relapses.

Stitt (1914) writes that “there now seems to be a tendency to use the alkaloid itself instead of its salts, it having been found that the alkaloid and its very insoluble tannate are absorbed from the digestive tract equally as well as the soluble salts.” Euquinine or ethylcarbonate of quinine contains 81 per cent. of quinine, but is expensive.

During malarial attacks, constipation must not be allowed. Headache can be relieved by cold applications, and perspiration must be encouraged in the early stage by hot tea, warm lime drinks, etc. After bad attacks, a change to a cooler climate is desirable, but the quinine treatment must not be discontinued.

Preventive measures take two main forms, directed respectively against the malarial parasites in man, and against the mosquitoes that convey the parasite from man to man.

With regard to man, houses should be built away from low-lying marshy ground, and kept free from vegetation such as grass or brush which furnishes shelter to the mosquitoes. In the tropics, the chief reservoirs of the malarial parasites are the native children, hence European quarters should be away from native dwellings as far as possible. Mosquito nets, having twenty to twenty-four meshes per square inch, should be used invariably, and houses should be screened. Malaria-conveying mosquitoes bite chiefly towards evening. Quinine treatment for preventive purposes is important. A dose of 5gr. of quinine daily, with a dose of 10gr. on the seventh day (Castellani), is efficacious. Some workers, however, recommend a large dose (15gr.) on two consecutive days every eight or ten days for three months, while others recommend 10gr. twice a week. Celli administered 3gr. of quinine morning and evening.

The second line of attack is directed against mosquitoes, especially Anophelines, on the lines so well set forth by Sir Ronald Ross.456 The accumulation of small quantities of water in various vessels, many of them unnecessary, should be prevented, as Stegomyia (Culicines) breed in such receptacles. Anophelines breed in small pools. All drinking water and household vessels, water-butts and cisterns must be effectively screened with wire gauze. Cesspools, etc., must also be screened, and they, and all collections of water, should be oiled with crude petroleum sprays every week or ten days, or fortnight according to some workers. The petroleum is a good larvicide and suffocates the Anopheline larvÆ, while its presence renders the site obnoxious to the adult mosquitoes. The amount of crude petroleum or kerosene will vary according to the locality concerned, due regard being paid to its powers of spreading on the surface treated. Different authorities have used different quantities, such as 1oz. of oil to 1 square yard or to 15 square feet. Others have used 1 pint of the petroleum to a circle of 20 feet in diameter, while 1/2 pint for every 100 square feet of surface has also been recommended. The larvicide used so successfully in Panama consisted of:—

One part of this mixture in 5,000 parts of water containing mosquito larvÆ destroys them within five minutes; 1 part in 8,000 of water kills larvÆ in thirty minutes. Small fish, such as the “millions” fish, that feed on the larvÆ, can be introduced into collections of water and are of local service. Ducks may also act as destroyers of larvÆ. The growth of water-weeds and rank vegetation, that affords shelter to the larvae, must be prevented as far as possible.

Wherever possible hollows should be filled up, swamps and roads should be well drained. Much good has followed the use of such measures in Panama, Egypt, British Guiana and other places. The ideal conditions for malaria reduction appear to consist in a combination of general quinine prophylaxis with anti-mosquito measures.

VII.—BALANTIDIAN DYSENTERY.

This disease is also known as ciliate or ciliary dysentery. The chief causal agent is Balantidium coli. Others are Balantidium minutum, Nyctotherus faba, etc. (see pp.200–206).

Balantidiasis is insidious and is marked by alternate attacks of diarrhoea and constipation with vomiting, while mucus is passed in the motions, which are foul smelling. There may be chronic ulceration of the colon. Œdema of the face and limbs and anÆmia may occur.

Treatment is at present rather unsatisfactory. Castellani and Chalmers state that “the symptomatic treatment for entamoebic dysentery may be tried.” Various treatments, more or less empirical, by calomel, quinine, carbolic acid in pill form, salicylic acid, extract of male fern, methylene blue, iodine solution, rice water and tannin enemata are mentioned by Prowazek457 (1913) and by Seifert. E.L. Walker458 (1913) found, from experimental work, that organic compounds of silver, e.g., protargol, were most effective. Local treatment by large enemata of collargol or protargol seems to be indicated. Behrenroth459 (1913) successfully treated a Prussian case with thymol, given in 4grm. doses every two days, followed at the end of a fortnight by de-emetinized ipecacuanha, given in pills containing 6 cg. each, to the number of thirty a day. In about another fortnight the symptoms had subsided. The thymol checked the diarrhoea, but it was necessary to give the de-emetinized ipecacuanha to kill off the balantidia still present. Phillips (1915) also recommends thymol. Ardin-Delteil, Raynaud, Coudray and Derrieu (1914) found neither emetine hydrochloride nor protargol of use.

As regards prophylaxis Walker states that pigs “should be confined and not allowed to run in yards and dwellings.” Behrenroth considers that dirty hands, for example, those of farm workers brought into contact with pigs, are probably the medium of infection. The personal cleanliness of such persons is, then, of the greatest importance.

PLATHELMINTHES (Flat Worms).
BY
J.W.W. STEPHENS, M.D., B.C., D.P.H.

FASCIOLIASIS.

Fasciola hepatica.

The symptoms of disease evoked by Fasciola hepatica are rarely observed in our part of the world, whereas Kermogant460 states them to be of frequent occurrence in Tonkin461; the parasites are there called “Douves.” In our experience they are only accidentally found post mortem in a certain number of cases, as no changes are manifested during life which would permit of any conclusion being drawn as to the presence of these parasites. In three cases (Bierner,462 Bostroem463 and Sagarra464) icterus was present; in a fourth case, recorded by Duffek,465 the parasites had led to a severe and acute distomiasis of the liver, combined with chronic purulent and ulcerative cholecystitis, with purulent cholangitis and dilation of the bile-ducts and numerous small abscesses of the liver. The total number of flukes found in these cases amounted to about fifty. The parasites passed from the duodenum into the bile-ducts, and first obstructed the flow of bile and then set up icterus, followed by cholecystitis and cholangitis.

As regards localization of the liver fluke in the pharynx, see p.242.

The treatment must be directed to the principal symptoms; prophylaxis is especially important in districts where distomiasis is of frequent occurrence. As the embryos live in water, only boiled or filtered water should be drunk. The attempts of Tappeiner466 to discover an effective remedy against liver-fluke disease (liver rot), so prevalent among sheep, were unsuccessful.

Fasciolopsis buski.

This parasite lives in the intestine, not in the liver of man; it produces bloody stools and typical symptoms—high fever and a condition of apathy (Odhner).467

PARAGONIMIASIS.

Paragonimus ringeri.

The disease produced by the lung fluke is specially endemic in Japan, also in isolated parts of China, Formosa and Korea. The fact that the lung-fluke disease is most frequently found in mountainous districts (Katsurada468) is worthy of special attention. The onset of pulmonary paragonimiasis is generally insidious (Looss469); generally the only symptom is a slight cough, occurring at first at longer, and later at shorter intervals; it is accompanied by the expectoration of discoloured sputum, frequently blood-stained. Though now and then severe hÆmorrhages result, up to the present no case has been established in which they have been the direct cause of death.

Examination of the thorax frequently fails to reveal anything abnormal. Inouye470 states that the most frequently observed changes consist in retraction of the thorax and in a contraction of its infrascapular portion. Scheube471 repeatedly observed that the one side, presumably that which harboured the worm, moved less freely than the other. The physical changes are not uniformly spread over the whole lung, but are localized. The disease may come to a standstill for long intervals and then set in again, lasting on the whole from ten to twenty years. In addition to paragonimiasis of the lungs, cysts are frequently found on the eyelids, which occasionally extend deeply into the orbit and hinder the movements of the eyes. Post mortem, cysts the size of hazel nuts containing one, two, or three adult worms are found in the lungs, and in addition, not uncommonly there exist pulmonary emphysema and bronchiectasis. Besides being present in the lungs and in the eyelids, the parasites have also been found in the pleura, the liver, the intestinal wall, the peritoneum, the cervical glands, and in the scrotum, without actually occasioning any actual symptoms in these tracts.

The most dangerous locality is in the brain. Otani,472 Inouye,473 Yamagiva,474 and recently also Taniguchi,475 have found post mortem the worms and their ova in tumours of the brain, or, in areas of softening in cases of Jacksonian epilepsy; in Taniguchi’s case the eggs were found in masses in the inflammatory areas of softening. In the nineteen cases of paragonimiasis of the brain collected by Inouye, the following symptoms were observed: general convulsions on eight occasions, unilateral convulsions on six occasions, convulsions with paralysis on the same side and hemiplegia, five times each; in Taniguchi’s case, attacks of cortical epilepsy, choreiform twitchings in the right extremities, which gradually become athetotic. The following were symptoms of rarer occurrence: paresis of the right upper extremity, vertigo, dementia, and amnesic aphasia, disturbances of vision. Paragonimiasis of the brain appears to arise by embolism from a primary pulmonary lesion.

The diagnosis depends upon the finding of ova in the sputa; if together with ova in the sputa, cerebral disturbances make their appearance, in all probability the cause is the presence of worms or ova in the brain.

The prognosis of pulmonary paragonimiasis is favourable; on the other hand, that of cerebral paragonimiasis is very doubtful.

The treatment of the pulmonary lesion consists only in paying attention to the general condition (good food, rest, cough remedies), as all attempts to destroy the worms in the lungs by means of vermicidal drugs administered internally or by way of inhalation have so far been without result. The treatment of the cerebral lesion is entirely hopeless. Trephining has been proposed for cases the condition of which is more favourable, but it has not reached the stage of performance.

Prophylaxis consists in general management: cleansing and if need be boiling of everything that is eaten or drunk.

Clonorchis sinensis.

According to our present knowledge Clonorchis sinensis is only found in China and Japan; even the post-mortem case reported by Laspeyres476 was that of an Asiatic sailor who was admitted into the General Hospital St. George, Hamburg, in a moribund condition with the clinical diagnosis of beri-beri. The bile-ducts are the usual site of the parasite, though Katsurada477 has found them also in the pancreatic ducts. In addition, it is found not uncommonly in the upper portion of the small intestine, especially in the duodenum, also, though decidedly rarely, in the stomach. As these sites, however, do not afford the conditions necessary to life, they are only found here on their way out of the body of the host.

The initial stage of infection with this fluke generally runs a symptomless course; in proportion as the worms multiply the following symptoms are manifested: First there is a morbid sense of hunger and irregularity in defÆcation; at the same time the patient experiences a feeling of pressure and pain in the epigastrium and right hypochondrium, or just a dull pain. Pressure increases the pain considerably. The liver appears to be enlarged, sometimes the enlargement is specially perceptible over the left lobe of the liver. The patients maintain a proportionately good general state of health in this state for a long time and may hope to recover. In severe cases there occurs copious and generally bloody diarrhoea, also icterus. The next stages are anÆmia, emaciation, epistaxis, ascites, enlarged spleen, and cachexia, to which the patient finally succumbs. In general the course of the disease is very chronic and irregular; in winter and spring there is generally improvement, in the summer and autumn the patient gets worse. At post-mortem the bile-ducts are enlarged and thickened, there is interstitial hepatitis with enlargement of the liver, but not to such an extent as in hypertrophic cirrhosis. After the initial enlargement contraction of the liver sets in, the peritoneal coat and capsule proper of the liver become more or less thickened in places. In the pancreas also dilatation and thickening of the ducts occur, as well as interstitial inflammatory processes. Obstructions in the portal circulation may lead to catarrhal changes in the stomach.

The diagnosis is based on the demonstration of ova in the fÆces.

As a radical treatment is still unknown, consequently it can only be purely symptomatic. Prophylaxis consists in the prohibition of drinking unboiled water or eating uncooked molluscs, fish, etc., of canal water. Leaving the epidemic region may bring about gradual recovery.

BILHARZIASIS.

Schistosoma hÆmatobium.

The symptoms of bilharziasis are manifested chiefly in the urinary apparatus, and above all as hÆmaturia, at the outset without any special troubles. Later, however, it is accompanied by subjective symptoms in the shape of feelings of pain, and of vague pains in the perinÆum and lumbar region, and of burning in the urethra during the passing of urine. All the symptoms are usually aggravated after excesses in eating and drinking, and after considerable bodily exertion. Another condition found, but not often mentioned, is lipuria (Stock478); the highest amount has been 2 per cent. fat in the urine. Stock found 6 to 20 per cent. of eosinophile cells in ten cases examined by him. They appear to be increased, especially in the early cases; Kautsky479 also called attention to the excessive degree of eosinophilia, whilst Goebel480 expresses the opinion that a specific toxic action on the organism generally is not developed in bilharziasis. Kautsky481 assumes a toxic anÆmia as in the case of ancylostomiasis. English authors also have called attention to the eosinophilia and to a considerable amount of leucocytosis (Balfour,482 Douglas and Hardy483). The severe forms occur almost exclusively in men; symptoms of catarrh of the bladder make their appearance, vesical calculi are frequently found, whilst the formation of stone in the kidneys and ureters is rare. Urethral fistula occurs in bilharziasis, often without stricture, and if granulations occur the fistula is distal to them. Goebel484 regards the bilharzia fistula as a chronic burrowing of pus, caused by the irritation set up by the ova as foreign bodies and consecutive restricted suppuration; and secondly as due to the passage of urine through the defect in the epithelium or the wall of the urethra. The fistulÆ, which are generally situated at the neck of the bladder and at the membranous portion, are very tortuous and frequently very numerous; they often lie embedded in well-marked tumours—in fact, in granulation tumours with marked inclination to excessive formation of cicatricial tissue. The opening generally is in the perineal and scrotal regions. In the case of a patient, aged 21, from the Transvaal, Kutner485 found by cystoscopic examinations the whole summit and walls of the bladder covered with large and small tumours. In addition to smooth glistening tumours, others were more or less disintegrated, and scattered large and small cauliflower-like growths occurred. Like malignant growths, the tumours were inclined to break down, the process extending from within outwards towards the surface. Whether the hydrocele so frequent in Egypt has any connection with bilharzia is not known. A frequent sequela of bilharziasis is complete sexual impotence (Petrie486).

Bilharziasis of the rectum is manifested by symptoms of dysentery; the repeated violent attempts at defÆcation lead in time to prolapse of the rectum, which sooner or later induces septic infection and so death. In the mucosa of the rectum, polypoid growths similar to those in the bladder are met with, due to the ova of the parasites in the mucosa and submucosa. In the case of a man, aged 36, who had lived for a long time in South Africa, Burfield487 found in the excised vermiform appendix ova of Schistosoma hÆmatobium; he assumed this to be a gradual secondary infection of the appendix, whilst Kelly488 mentions a case of primary bilharziasis of the appendix; the eggs lay in the submucosa directly above the muscularis. Tumours containing numerous ova are frequently found in the region of the genitalia, thighs and scrotum. In one case Symmers489 found numerous male schistosomes in the portal blood and a copulating pair in the left lung. Though schistosome eggs have been found by some observers in the lung tissue, this is nevertheless the first case in which living parasites have been found in the lesser circulation. Perhaps they got there by way of the external iliac vein from the veins of the bladder and rectum.

In the female sex bilharziasis is incomparably rarer than in the male and is generally limited to hÆmaturia. Bilharziasis of the vagina, which takes the form of an acute vaginitis, is frequent according to Milton.490 Horwood491 found in one case a polypoid tumour of the cervix uteri, and in the connective tissue of the tumour Schistosoma ova, both in masses and singly. It could not be established whether the ova reached the vagina and thence the cervix directly, or through the urine from the bladder.

The course of the disease is chronic, and in slight cases, provided fresh infections do not occur, is not unfavourable; in severe cases the cachexia caused by loss of blood, or intercurrent diseases to which the patients easily succumb—e.g., pyelitis, pyelonephritis, pyÆmia, or urÆmia—lead to a fatal issue.

In regions in which Schistosoma hÆmatobium is endemic, or in patients from such regions, the diagnosis is easy by microscopically finding the eggs in the urine.

As regards the treatment of the affection this much must be said, that so far there is in existence no certain remedy. In countries where bilharziasis is endemic copaiva balsam is considered a specific. Kutner (loc. cit.), however, in the case of his patient who for a long time had taken no inconsiderable amounts of copaiva, had no success worth speaking of to record. Urotropin (three times daily, 1grm.) has similarly failed, salol (0·75grm. several times daily) perhaps affords relief in affection of the bladder (Milton). Methylene blue, oil of turpentine with extract of male fern (Brock492), or the latter alone and santonin given in small doses for a week at a time, in the morning, are said by Petrie493 to be of value. Sandwith494 and Harley495 were not very successful. By way of experiment Kutner for some time used collargol per rectum, proceeding on the assumption that this preparation, which has proved of such remarkable service in bacterial infection, would perhaps render a continuance of life difficult for the bilharzia worms. But this hope proved illusory. In order so far as possible to limit the loss of blood, Kutner regularly employed stypticin for long periods (three times daily, two tabloids of 0·01grm.) with undoubted success, in so far that the hÆmorrhages became considerably less in amount. As two patients in the course of enteric fever lost their hÆmaturia, Stock accordingly recommends subcutaneous injections of Wright’s typhoid vaccine. In the early stages of the rectal lesion suppositories of iodoform, ichthyol, or narcotics might possibly be of use. In the case of urethral fistulÆ, division, excision and scraping out of the granulation tissue are recommended; in cystitis with formation of tumours high resection with curetting of the tumours or their destruction with the cautery; in the case of vesical calculi, high resection, curetting the bladder, and then drainage. Tumours of the rectum must also be removed by operation.

Prophylaxis is important; it should be extended to all modes of using water, only filtered water being drunk, and only boiled water being used for washing. This advice should be given to tourists who travel through the infected districts, and is also recommended to soldiers and officials who are despatched to the Colonies. The favourable influence of change of climate can only show itself where fresh infections are avoided.

CESTODES.

GENERAL.

It seems advisable to preface the section on the Cestodes with some general observations on the symptoms of disease provoked by tapeworms, especially so far as they relate to the question of toxic effects, and to include the Nematodes in this discussion. After this will follow a brief exposition of the most important intestinal lesions causally connected with intestinal parasites.

It is known to every experienced practitioner that the different intestinal parasites can give rise to a series of nervous symptoms, slight or severe, and produce, above all, blood changes—anÆmia of the most varied nature, to the extent of severe progressive anÆmia. These symptoms are regarded by many authors as reflex, or, as in the case of ancylostomiasis, the main feature from the loss of blood caused by the habit of life of the intestinal parasites. More frequently, however, they are regarded as toxic conditions produced by the parasites. In view of this divergence of opinion there appears to be some advantage in defining clearly the present position as to the toxic action of parasites. Most interesting in this respect are Dibothriocephalus latus and Ancylostoma duodenale.

We are indebted to the clinic at Helsingfors for our most detailed knowledge of bothriocephalus anÆmia. Reyher496 was the first to demonstrate that this parasite under certain circumstances can produce a severe, progressive and sometimes fatal anÆmia, which can be cured, generally in a surprisingly short time, by expulsion of the worm. Among the various hypotheses which have been advanced as to the mode of origin of bothriocephalus anÆmia, the greatest importance has been attached to the assumption already mentioned by Reyher, but definitely expressed by von Shapiro,497 to the effect that Bothriocephalus latus produces a poison which is absorbed by the intestine and exercises a deleterious influence on the composition of the blood, especially on the erythrocytes, perhaps also on the blood-forming organs. This assumption is supported by no slight number of clinical and experimental investigations. Podwissotsky498 observed severe blood changes in a child, aged 4 1/2, affected with B. latus. In the case reported by Pariser499 the severe anÆmia in a girl disappeared fairly soon after expulsion of the worm. In that reported by Schaumann500 high fever accompanied the bothriocephalus anÆmia; he also proved the hÆmolytic properties of the broad tapeworm. The case reported by F. MÜller501 was one of severe anÆmia. Also, in the first of the cases described by Kurimoto502 of Diplogonoporus grandis there were present the same symptoms of anÆmia as in the case of B. latus. Meyer503 observed severe anÆmia in two youths caused by B. latus. Rosenquist504 has discussed the proteid metabolism in anÆmia. The presence of B. latus produces in the majority of cases an increased proteid consumption, to which the blood change generally corresponds—toxic anÆmia; in a further communication he reports on twenty cases of bothriocephalus anÆmia, nineteen of which were cured by expulsion of the worms, while one case proved fatal, and he again emphasizes the toxic properties of the intestinal parasites. In the case reported by Bendix,505 that of a girl, aged 4 1/2, the anÆmia was moderate, whilst in the case of Zinn506 (a woman, aged 30) the anÆmia was so excessive that the patient succumbed five days after expulsion of six bothriocephalus heads. Isaac and van den Velden507 have established that in the serum of patients who suffer from anÆmia due to B. latus, parasitic products are dissolved, as shown by a distinct precipitin reaction. Galli-Valerio508 considers it likely that toxic substances are secreted by the living helminthes which produce a lowering or raising of the body temperature, nervous disturbances and hÆmolysis. Tallqvist509 succeeded in extracting from B. latus a lipoid-like body which had a strong hÆmolytic action. The experimental anÆmia thereby produced differed in no respect from the severe chronic bothriocephalus anÆmia of man. The question as to under what special conditions severe, and sometimes fatal bothriocephalus anÆmia is developed is answered by Leichtenstern510 and by Lenhartz,511 by the assumption that among the Bothriocephali some are toxic, that is, manufacture a poison which, when absorbed by the host, produces a severe anÆmia.

Certain factors lead him to conclude that an accumulation of poison, dependent on time and place, occurs in the Bothriocephali.

In the case of ancylostome anÆmia, experience so far, according to Leichtenstern,512 by no means supports the hypothesis of a difference in virulence of the worms according to time and locality, ancylostome anÆmia being rather, so far as is known at present, in all races of man, everywhere and at all times, simply and solely dependent on the number of ancylostomes, the duration of the disease and—within certain narrow limits—on the individual capability of resisting the loss of blood and the toxic effect of the parasites. As is shown by a short historical rÉsumÉ of the toxic action that has to be considered in ancylostome anÆmia, we must admit that doubtless here, as in the case of bothriocephalus anÆmia, the toxins secreted by the parasites exercise a hÆmolytic action, even while admitting Leichtenstern’s contention that the significance of the loss of blood due to ancylostomes must not be underrated. The toxic hypothesis acquired a definite standing through a series of experiments of Lussana513 on rabbits, where he succeeded in producing anÆmia by injecting urinary extracts of ancylostome patients. Arslan514 extracted toxins from the urine of two ancylostome patients and injected them into rabbits, which thereupon sickened and showed the same blood changes as the ancylostome patients. Retinal hÆmorrhages, so frequent in ancylostome anÆmia, which, according to Fischer515 and Samelsohn,516 are not due to direct loss of blood, must also be ascribed to a parasitic toxin. A further argument in favour of the toxic hypothesis is furnished by the blood changes recorded by Zappert,517 MÜller and Rieder,518 BÜcklers,519 and Neusser,520 which must be regarded as the expression of toxic action, especially with reference to eosinophilia. The striking increase in proteid destruction in ancylostomiasis observed by Bohland,521 and which ceased after the parasites had been expelled, also gives additional support to the assumption of toxic action. The observation of Daniels522 also deserves consideration in this connection, according to which the presence of yellow pigment in the liver and kidney cells is to be attributed to blood destruction by a verminous toxin absorbed from the gut. Looss523 considers it not at all improbable—in fact, almost certain—that Ancylostoma, in addition to withdrawing blood, exert a kind of toxic action on their host.

Scheube524 attributes almost equal importance to the loss of blood, the digestive disturbances, and the intoxication induced by certain metabolic products of the parasites. According to v. Jaksch525 ancylostome anÆmia is not induced solely by loss of blood, but by the fact that the parasites produce a ferment which has a toxic action and produces stimulation in those organs in which the eosinophile cells arise. The hÆmolytic action of ancylostomes has frequently been observed by Galvagno526 in men employed in sulphur mines. According to Loeb and Smith527 the anterior half of the body of ancylostomes contains a substance which probably causes anÆmia. Bauer528 found in the urine of ancylostome patients glycuronic acid, which he considers to be a sign of metabolic disturbance due to parasitic toxins. As has been demonstrated by Allessandrini,529 the secretion of glands in the anterior part of the body has a distinct hÆmolytic effect on the erythrocytes. While the worm attaches itself to the mucosa by means of its teeth, these glands discharge their secretion, producing hyperÆmia. The extravasated blood is acted on by this secretion, so that it can serve as food for the parasites. Hynek530 attributes eosinophilia (up to 20 per cent.) to a toxic action. Goldmann531 expresses a similar opinion, though he assumes that the anÆmia is secondary, as the toxin of the cephalic glands, as the parasites bite, penetrates the mucosa and thence into the blood, where it dissolves the red blood corpuscles. Romani532 discusses the agglutinating hÆmolytic action of the serum of ancylostome patients. Whether Ancylostoma produce toxins and what is their nature, or whether the loss of blood causes the anÆmia, Liefmann533 was unable definitely to determine; hÆmolytic substances do not appear to take any part in it.

Berti534 also is inclined to attribute the anÆmia to metabolic products of the ancylostomes; he found, in fact, that a serum obtained from a sheep (after subcutaneous injections of the culture fluid of ancylostome larvÆ) was efficacious in the treatment of ancylostome anÆmia. Peiper535 likewise assumes that the parasite secretes a cell toxin. LÖbker536 at the present day still maintains that the cause of the disease must be looked for really, if not perhaps entirely, in the continued withdrawal of blood by the parasites; the secretion of toxins by ancylostomes has not yet, in his opinion, been conclusively proved. Except in the case of Bothriocephalus latus, referred to previously, toxic action appears to be of quite subordinate importance for the other Cestodes occurring in man—especially TÆnia solium and T. saginata, which are most frequently found; thus Cao537 flatly denies the presence of toxins in the body of TÆniÆ, while others, such as Messineo and Calmida,538 Jammes and Mandoul,539 consider they are justified from their investigations in concluding that TÆniÆ contain a specific toxin. Messineo540 injected, with all bacteriological precautions, extracts of TÆnia, dissolved in physiological salt solution. He invariably obtained severe motor disturbances and frequently death. The observation by Pereira541 of a case of chorea in which rheumatic and cardiac symptoms were absent and which after expulsion of a TÆnia was quickly cured, also favours the view of a toxic action. Barnabo,542 however, was unable to obtain a toxin from TÆnia saginata. Gagnoni,543 on account of a marked eosinophilia which, after expulsion of a TÆnia saginata, fell within fourteen days to 1 per cent., assumes the formation of a TÆnia toxin. Dirksen’s544 observation has reference to a sailor affected with serious anÆmia, who, after expulsion of twelve pieces of TÆnia solium, was rapidly cured. A portion of the worm was already breaking down, the absorption introducing into the body highly toxic hÆmolytic products, to which the anÆmia must be ascribed. How far the serious disturbances of the nervous system, frequently to be observed in cases of Hymenolepis nana, are to be considered as of purely reflex nature or toxic must remain an open question; the same applies to Dipylidium caninum, in which case Brandt545 observed serious central nervous symptoms. Caution is necessary in judging as to any connection between worm stimulus and nervous symptoms in cases of Ascaris infection. Peiper546 is inclined to regard such nervous symptoms not as reflex, but rather as due to a toxin contained in the helminthes, or metabolic in origin.

In cases of pernicious anÆmia when the symptoms disappear after expulsion of AscaridÆ a toxic action must be assumed (Demme547). Additional clinical observations do not, indeed, lead to any definite conclusion as to the question whether AscaridÆ produce a toxin which is capable of causing more or less injury either to the nervous system or to the blood, yet it may be worth while to give a brief review of this question. In a case of Kutner’s,548 that of a girl, aged 12, there was a hÆmolysis which was cured after expulsion of twenty-four AscaridÆ. Attacks of opisthotonos in a girl, aged 16, ceased after seventy-eight AscaridÆ had been expelled (Lutz549). Unusually serious disturbances were observed in a man, aged 26, who was rapidly cured by Drouillard550 by the removal of a great number of AscaridÆ. The observations on pseudomeningitis are of especial interest; they are evidently toxic in origin as in the case of Annaratone,551 of a man who was taken ill with gastro-intestinal symptoms and who died with meningitic symptoms. Post mortem the brain was normal, but the stomach contained a great coil of AscaridÆ. The cases of Delille,552 MÉriel,553 Papi554 (the occurrence of Cheyne-Stokes respiration has been ascribed to the action upon the centre in the medulla oblongata of the products of the AscaridÆ), and Taillens555 related to children in which the meningitic symptoms (meningismus), partly serious, disappeared with the removal of the AscaridÆ. MÁreo556 designates this disease helminthiasis meningitiformis, which exhibits all the symptoms of meningitis, but which is caused by the metabolic products of AscaridÆ.

Schupfer,557 Duprey558 (observations in the West Indies, where such symptoms are said to be of very frequent occurrence), Naab559 (the flow of water from the mouth at night is mentioned as a remarkable fact), and Hammiss560 assume the action of an Ascaris toxin in the clinical observations made by them, mostly children with fever and intestinal symptoms. Schupfer assumes in such cases, as he observed it once in a man, aged 23, that the disease termed Lombricoise À forme typhoÏde by Chauffard was due to B. coli of marked virulence due to the action of the AscaridÆ. The Widal reaction was negative. Koneff561 reports a case in which acute attacks of cramp, trismus, and rigidity of the pupil disappeared after expulsion of seven AscaridÆ. Tetanus, as observed by Buchholz562 in a girl, aged 17, and rapidly cured after expulsion of sixteen AscaridÆ, is manifestly rare, since only Rose563 mentions this as a cause in his article on Tetanus. Only a few experimental data exist. Cattaneo564 could detect only a very weak toxin in Ascaris, while Messineo,565 by injecting into animals extracts in physiological salt solution, invariably succeeded in producing serious motor disturbances and frequently death. Interesting also are the observations of Huber,566 who, after working with AscaridÆ, suffered from itching of the head and neck, blisters, swelling of the ear, conjunctivitis, ecchymosis and troublesome palpitation in the head. He consequently assumes that AscaridÆ can induce irritation by chemical (toxic) means.

In the case of Trichocephalus dispar no more than in the case of Ascaris lumbricoides can we speak with certainty of a toxic effect, even though a number of observations are available which might justify such an assumption as regards these intestinal parasites. Barth567 found the brain normal in a man who had died with meningitic symptoms, but the intestines were full of Trichocephalus dispar; Gibson568 records the rapid cure of serious cerebral symptoms after expulsion of Trichocephalus, so also Pascal,569 Burchhardt570 and Rippe.571 Moosbrugger572 was the first to draw attention to grave anÆmic conditions induced by Trichocephalus, Morsasca573 and Becker574 to progressive grave anÆmia (trichocephalus anÆmia is accompanied by marked reduction of the number of red blood corpuscles, of the specific gravity and of the hÆmoglobin, well-marked morphological changes of the red cell, micro-, macro-, and poikilocytosis and nucleated red cells). Sandler,575 in his case of a boy, aged 11, who died of anÆmia, assumes a trichocephalus toxin to be the cause of the disease, and Kahane also reports on anÆmic conditions induced by Trichocephalus. Girard,576 in addition to symptoms in the gastro-intestinal tract, calls attention to those arising in the blood—anÆmia and its sequelÆ—and also to nervous symptoms: cerebral phenomena, headache, giddiness, aphonia, symptoms of meningitis. In a case of Schiller’s577 high fever was present, which probably set in when the Trichocephali present in the gut in great numbers commenced their parasitic activity. Hausmann,578 in order to explain the adaptability of Trichocephalus, assumes that according to the locus minoris resistentiÆ, at one time the reflex at another the toxic action is effective, now on one organ, then on another; anÆmia being present in most cases, frequently general and local neuroses and cerebral symptoms of various kinds.

With regard to the toxic action of Oxyuris there is only the single record of Hartmann,579 who noticed the disappearance of epileptic fits and psychic disturbances in a girl, aged 13, after the removal of Oxyuris. Nervous disturbances and blood changes can but rarely be attributed to Strongyloides. Silvester580 and Valdes581 report on giddiness, headache and anuria in cases observed by them; whether the eosinophilia recorded by BÜcklers582 and Bruns583 is due to the toxin of Strongyloides must remain an open question.

Reference has already been made to the possibility that intestinal ciliates (Balantidium coli) can also produce toxins.

The contents of echinococcus cysts appear to contain a substance only moderately toxic, giving rise to urticaria, in a series of cases where the fluid has escaped into the abdominal cavity (during puncture). D. MÜller584 has collected nine such cases out of the literature, to which may be added six cases of Finsen585 in which the escape of fluid into the peritoneal cavity led to severely itching urticaria, which usually disappeared again after one or two days. On one occasion, indeed, urticaria occurred after rupture into the pleural cavity. In the case recorded by Caffarena586 of echinococcus of the right lobe of the liver, widespread urticaria developed as the result of the exploratory puncture. In the case of an echinococcus of the liver rupturing into the abdominal cavity La Spada587 ascribed the symptoms leading to death to toxic influence while the peritoneal symptoms were less marked. Eosinophilia in hydatid disease is slight according to the investigations of Bindi588 and Santucci,589 and is, according to Welsh and Barling,590 no certain sign of echinococcus; it is independent of the age, sex and temperature of the patient, but upon rupture of the cyst eosinophilia invariably sets in.

The question as to the importance of helminthes in relation to certain diseases of the gut requires special discussion, but it concerns only Ascaris lumbricoides, Oxyuris vermicularis, and Trichocephalus dispar, and the question of appendicitis first of all. The entrance of intestinal parasites into the vermiform appendix was already known to medical men in the fifties of last century, as is shown by the works of Merling591 (1836), Zebert592 (1859), Platonor593 (1853), and Schachtinger594 (1861). Most of these authors have considered intestinal worms, together with other foreign bodies, to be the cause of appendicitis. As regards the part played by these intestinal parasites in the etiology of appendicitis, so much discussion has taken place during the last few years that it is worth while to give a rÉsumÉ of the later views on this question, even though at the outset it must be admitted that the matter is not cleared up. Bergmann595 records a case in which an Ascaris perforated the appendix and got into the peritoneal cavity.

StrÜmpell596 reckons among the symptoms of Trichocephalus the possibility of a “typhlitis.” On account of the marked sensitiveness of the ileo-cÆcal region, Boas597 mentions the possibility of confusing it with appendicitis. Still598 regards Oxyuris as a principal cause of catarrhal affections of the appendix. ArborÉ-Rally599 regarded severe symptoms of appendicitis in a boy, aged 10, as due to Ascarides. In all cases of appendicitis Metschnikoff600 requires a microscopical examination to be made for eggs, and considers treatment for worms carried out otherwise as a cause of the frequency of perityphlitis. Matignon601 does not agree with this opinion, as in spite of the extraordinary frequency of intestinal worms in China, he has only seen one case of appendicitis in four and a half years, and Des Barres602 expresses himself in similar fashion. Out of twenty-one cases of appendicitis Kirmisson603 discovered the ova of Trichocephalus eighteen times and the ova of Ascarides in three of these cases; in twelve cases of enteric fever the examination for eggs was negative nine times. Moty604 considers Oxyuris to be the sole cause in his three cases of appendicitis. Girard605 ascribes to Trichocephali the rÔle of more or less septic foreign bodies which may bring about the entry of intestinal bacteria into the appendix, and Triboulet606 describes a case of appendicitis which he considers was due to Ascaris. In Morkowitin’s607 case numerous Oxyuris had clearly caused the appendicitis. von Genser608 records the case of a boy, aged 5, who was operated on for appendicitis, and who passed through the operation wound a living Ascaris on the eighteenth day after the operation. In the first case communicated by Schiller609 the disappearance of the typhlitic swelling after the discharge of the Ascarides pointed to the etiological significance of the parasites, and the same obtained in a further case published at an earlier date by Czerny and HeddÄus.610 In a case abstracted by Kaposi611 Trichocephali appear to have been a contributory cause in the production of the appendicitis. In a further case reported by Schiller, where the appendix was removed, it was shown that Oxyuris had given rise to a pronounced appendicular colic. In a girl, aged 13, who died from diffuse peritonitis, Schwankhaus612 found that an Ascaris had perforated the appendix. Ramstedt613 found in an extirpated appendix a whole “tangle” of Oxyuris, and believes in the possibility of their having provoked the inflammation; he recommends an examination for entozoa before the operation, without, however, after Metschnikoff’s example, substituting worm treatment for the operation. Rostowzeff614 ascribes only a minimal direct etiological significance to intestinal worms in the origin of appendicitis; in 163 cases he found worms in three instances. Wirsaladze615 expresses himself in a similar fashion. Oppe616 observed Oxyuris six times in excised appendices, and emphasizes the opinion that in appendicitis the question of a worm cure ought to be taken into consideration. Ascaris and Oxyuris, if no contra-indication exists, may be expelled, but in the case of Trichocephalus, which frequently defies all expulsive treatment, no attempt should be made, but operation proceeded to forthwith. In a case briefly reported by Hanau617 Oxyuris was undoubtedly the etiological starting-point; in a case of Galli-Vallerio618 Oxyuris and Trichocephalus. In the opinion of Ssaweljews619 in some cases of appendicitis, in addition to other causes, intestinal parasites play a prominent part. The case recorded by Nason620 is an interesting one; in this an Ascaris in the appendix became twisted with it round a coil of gut, causing obstruction. Spieler621 argues against the underestimation by many authors as to the part played by intestinal worms in producing appendicitis, although he also does not regard them as a frequent, to say nothing of an exclusive, cause of the disease. In a case recorded by BÉgonin622 fifteen Oxyuris were found in the excised appendix (the mucosa showed some ulceration), and in another recorded by Putnam623 twenty Oxyuris were present in the appendix, in which there was no evidence of any change. The standpoint Schilling624 takes is to the effect that entozoa irritate the mucosa and can increase an already existing inflammation, but he considers it very questionable whether they can produce appendicitis. Blanchard625 assumes the possibility of a secondary infection arising from lesions of the mucosa produced by helminthes (Ascaris and Oxyuris). Moore626 considers Trichocephalus the excitant of the appendicitis in his case. In a second case of appendicitis recorded by Auley627 operation became unnecessary owing to the passage of the AscaridÆ. Page’s628 case is an interesting one; it was that of a man who came up for operation with a diagnosis of appendicitis. On incising the abdominal wall numerous Ascarides were found at the base of the wound, lying in cavities; even after eight days Ascarides escaped from the wound. The author assumes there was a perforation of the gut wall; it is strange that the worms were able to exist a proportionately long time in the muscular tissue. Schoeppler629 states that there is the danger of an appendicitis even after the death of an Oxyuris that has found its way into the appendix. Oui630 met with two specimens of Trichocephalus which had become embedded by their thin ends deep in the mucosa. Frangenheim631 is not in a position to pronounce any opinion as to what part intestinal parasites play in the etiology of appendicitis. In a case recorded by Kahane632 many Trichocephali were found partly free in the appendix and partly embedded in the mucosa; microscopically appendicitis was diagnosed. At a laparotomy for salpingitis Heekes633 found the appendix elongated, thickened, and containing about eleven Oxyuris without the mucosa being in any way changed. In one case Andrews634 claims Ascarides to have been the direct cause of the appendicitis. The literature dealing with this question, so important in our time, has been collected almost without any omissions, but, unfortunately, no decisive opinion as to the significance of parasites in appendicitis can be inferred from it. The vexed question whether intestinal parasites, especially Ascaris, are able to penetrate the intestinal wall is just as little finally decided. Leuckart,635 Heller,636 Mosler and Peiper,637 Henoch,638 Davaine,639 KÜchenmeister,640 and Bremser641 are opposed to the idea that the healthy intestinal wall can be penetrated by intestinal worms, especially Ascarides, whilst a whole series of other authors are of the opinion that even the healthy intestinal mucosa can be perforated. Among these is numbered MondiÈre,642 who is of the opinion that Ascaris, by violent pressure against the mucosa, forces it so much apart that it is enabled to escape through the gap thus formed into the peritoneal cavity; this opinion is shared by v. Siebold.643 Rokitansky644 considers perforation of the gut by Ascaris as at least a rare occurrence. Gerhardt645 does not doubt that the worms can actively perforate the intestine. Cases like those of Abrault,646 Apostolides,647 Marcus648 (recorded by Perls as a valid example of “ascaridophagous” gut perforation), Wischnewsky,649 Galvagno,650 Salieri651 certainly show that perforation of the healthy gut wall cannot be denied, but at the same time that this occurrence, compared with the frequency of AscaridÆ, should be regarded as exceedingly rare. It is another matter as to whether it is possible for the worms to penetrate an intestinal wall already diseased, especially when ulcerated; a whole series of observations are in favour of this. In Lini’s652 case (fifty-six Ascarides escaped from the umbilicus of a girl, aged 7), in GrÄffe’s653 (eighty Ascarides escaped from an inguinal tumour), in Nicolino’s654 (perforation of the intestinal wall with strangulated hernia), in Liesen’s655 (a living Ascaris in the peritoneal cavity in a woman suffering from a peritoneal abscess)—in these it is clear that disease processes in the intestine preceded the exit of the worms. In a case described by Boloff656 the Ascarides appear to have produced, by forming a tight coil, necrosis of the gut with perforative peritonitis. In a case recorded by Lutz657 the perforative peritonitis was without doubt provoked by Ascaris, and in one by Schiller658 the Ascaris had clearly gained access to the peritoneal cavity through a gunshot wound opening. In a case observed by Rehn659 the worm probably entered through a gangrenous portion of the intestine in a hernial sac. Broca660 is unable to determine whether in his case the intestinal perforation was primary (a worm escaped from the abdominal wound about two months after a laparotomy for suppurative peritonitis). The case reported by Lutz661 is of special interest: it was that of a young man who had shot himself in the region of the abdomen, and who died after fifteen days. At the post-mortem two Ascarides were found in the pulmonary artery; they had probably escaped from the intestine, and had gained access to the inferior vena cava. Froelich662 assumes that in his case (a boy, aged 11) the Oxyuris were able to penetrate the whole intestinal wall, but Vuillemin663 considers this improbable, and is more inclined to think that the Oxyurides penetrated the rectum at small ulcerated points, and thus gained access to the perirectal connective tissue. In females Oxyuris not only have the power of penetrating far into the sexual organs (Marro664), and perhaps causing a parasitic endometritis (Simons665), but also clearly of gaining access to the peritoneal cavity by way of the tubes, as is to be assumed in the case recorded by Kolb666 (that of a woman, aged 42, in whom post mortem nodules were found over the peritoneum of Douglas’s pouch, in which the pressure of encapsuled Oxyuris could be demonstrated), in that reported by Chiari667 (adult Oxyuris in Douglas’s pouch) and by Schneider668 (an Oxyuris encapsuled in the pelvic peritoneum). Sehrt’s669 case is worthy of attention; in this an abscess was found in the omentum with numerous Ascaris ova in the pus and a nodular lesion of the peritoneum, with Ascaris ova encapsuled in the nodules. Massive accumulation of Ascarides may give rise to a complete occlusion of the gut. Such an occurrence is not so surprising as might be thought when one reflects that the number of Ascarides in one individual may amount to several hundreds. For instance, one boy evacuated within a single day 600 Ascarides (Fauconneau-Dufresne670) and within three years 5,126 worms. In the case recorded by Tschernomikow671 a boy, aged 2 1/2, evacuated during a day 208 worms, partly through the stomach, partly through the intestine. Coil-formation of such masses of Ascarides renders possible not only constipation, but also complete obstruction with symptoms of ileus, as shown by the five cases quoted by Mosler and Peiper,672 as well as from observations made by Raie,673 Schulhof,674 Rehberg,675 Rocheblave,676 Heller,677 Leichtenstern,678 Huber,679 and Wilms.680 In two cases of Black681 and Parkinson682 the intestinal obstruction was caused by a coil of tapeworms.

In the earlier history of medicine the helminthes played a great part as the excitants of many intestinal diseases and of enteric as well. Even if to-day they no longer be regarded as such, the conception that they represent the predisposing factor in typhoid infection through the injury they inflict on the mucosa (Guiart,683 Blanchard,684 Vivaldi and Tonello685) must not be summarily rejected. Vivaldi and Tonello found helminthes in 80 per cent. of their typhoid patients, numbering among these Trichocephalus dispar, Oxyuris vermicularis, Ancylostoma duodenale, and AscaridÆ. The report of Leuckart686 is here worth citing, to the effect that Thiebault never failed to find Trichocephalus in his cholera patients at Naples. Blanchard687 goes so far as to express the desire that in every febrile affection of the intestine an anthelmintic treatment with thymol should be undertaken as early as possible, even before learning the results of serum diagnosis.

The lesions of the liver and pancreas due to AscaridÆ are briefly discussed in the chapter on Ascariasis (p.687).

A discussion of the intestinal helminthes from the clinical and therapeutical point of view follows these general considerations.

Dibothriocephalus latus.

From what is known as to the development of Dibothriocephalus latus, the way by which man is infected is self-evident: infection can only take place through the ingestion of insufficiently cooked fresh-water fish (pike, burbot, perch, grayling and vendace); what degree of temperature is necessary to kill the larval forms is still unknown. Dibothriocephalus latus lives in the small intestine of man, alone or in some numbers, frequently also together with TÆnia solium. The proglottides are passed always united in large pieces, the ova are deposited through the uterine pore, while the worm is still in the intestine, so that they are easily found in the fÆces. The proglottides are so characteristic that they cannot be confused with those of other species. In reference to whether age or sex is spared by D. latus, it is not possible to make any definite statement, especially so far as the endemic area is concerned, whether a person resides in it continuously or visits it, so long as his habit of life is in accordance with those of the country. Bendix688 certainly emphasizes the fact that early childhood is as a rule immune: his case was that of a child, aged 4 1/2 years.

Sparganum mansoni.

According to our present knowledge (Miyake689) the disease occurs almost exclusively in China and Japan. On the main island it occurs in all districts, though rarely under observation. It is especially frequent in the neighbourhood of Kioto and Osaka; these places are very near together, and between them there is mutually active intercourse, so that taken together they may be regarded as one district infested by this worm disease. As regards localization in the body, there appears to exist a certain predisposition for definite regions, for instance, the eye and genito-urinary tract. In some cases the parasite manifested the peculiarity of wandering about the body and of appearing at certain favourite points (musc. quadriceps femoris) (Hashimoto690). Most patients complain more or less of the onset of attacks of pain and of sensitiveness to pressure. In those cases in which the patients evacuated the worm during micturition, the symptoms were variable; sometimes there was tenesmus of the bladder, sometimes pains in the inguinal region, sometimes hÆmaturia. None of these troubles is characteristic of the disease, and does no more than represent the symptoms that follow a mechanical irritation that any kind of foreign body may produce. Besides the onset of attacks of pain, swelling of the regions affected, if superficial, may often be recognized, when a superficial diffuse soft tumour can be felt which often gives pseudo-fluctuation. Sometimes a peculiar crackling can be detected internally, as in the making of a snowball. During the further course an abscess not infrequently forms around the worm. When the situation of the worm is superficial, “an inflammatory tumour with a tendency to migrate” is stated by Omi691 to be an important diagnostic sign. That, however, is not always the case, as the observation made by Inoye692 shows. It would be better to add to this sign the onset of paroxysmal pain and the temporary change in volume of the tumour. When once the parasite is removed, the wound heals just as satisfactorily as any other fresh wounds made at operation.

Dipylidium caninum (TÆnia cucumerina).

This species belongs to parasites of rare occurrence. Up to the year 1905 Bollinger693 collected thirty-six cases from the literature, twenty-nine of which were children and seven adults. Since then some further cases have come to light, so that the number now observed amounts to ninety, and among them only eight adults. The youngest child was 6 weeks old (KÖhl694), in which the first proglottides were passed when the child was 40 days old. This preponderating occurrence in children is clearly connected with the close intercourse between children and dogs, and also cats. Bollinger believes that D. caninum in reality occurs more frequently in adults than has hitherto been supposed. In addition, it must be mentioned that this species is quite unknown to many physicians, and is occasionally confused with TÆnia solium. One notices almost daily a large quantity of cucumber-seed-like bodies, reddish or whitish-grey, about 1cm. long and 2mm. broad, discharged with the stools. Lindblad695 remarks that these bodies have lively movements, that they perish rapidly in fresh water, and become white and smooth. These Cestodes, in isolated cases, are parasitic in the intestine in large numbers. Sonnenschein696 expelled four fragments in the case of a boy, aged 4 months; Asam697 three fragments in the case of a child, aged 19 months; and Zschokke698 as many as five or six in that of a boy, aged 4. They do not always produce such striking symptoms as occurred in Pollak’s case.699 In other cases gastro-intestinal disturbances with or without fever (KrÜger700), emaciation (Zschokke), or even nervous symptoms of central origin in the form of convulsions (Brandt701) have been observed. From the nature and mode of infection children must be kept from close contact with dogs and cats as much as possible to ensure prophylaxis. The appropriate treatment, as it mainly affects children, deserves special mention, whilst the expulsion of the remaining Cestodes may be described in this connection. Among the drugs one may mention flor. kousso 1·0grm., pulpa tamar. depur. 2grm., syrup of sugar 50·0grm., one-third to be taken every hour (Lindblad). Kamala appears to have no effect, although Huber702 recommends it in small doses according to age from 0·5 to 3·0grm. He warns against Filix mas preparations, which otherwise, even in early childhood, under careful dosage gives the best results. Young children are given 1·0 to 2·0grm. extr. fil. maris, with mint syrup or raspberry syrup 30·0grm., in the morning twice an hour by the mouth, or 1·0grm. extr. fil. maris is mixed with syrup of mint, and given by means of a stomach tube (Rosenberg703). A few hours afterwards a mild laxative may be taken—one to two tablespoonfuls of aqueous tincture of rhubarb (Asam)—or an enema may be given. In a case reported by Sonnenschein decoction of pomegranate root had no effect, as it was vomited up.

Hymenolepis nana.

This species, very rare in Central and Northern Europe, inhabits the small intestine, especially of children; it burrows very deeply into the mucosa. Not uncommonly several thousand have been found in one case (Nicolo,704 E. Stoerk and Haendel705). It is remarkable that these Cestodes have been found so frequently post mortem and after vermifuges given for other reasons. Thus the clinical symptoms must often be very indefinite (Stoerk and Haendel), so that one may assume that only a slight percentage of cases of Hymenolepis nana come under observation and are published as such. On the other hand, it is certainly conceivable that with the large number of parasites that frequently occur in one individual a whole series of symptoms, in part quite severe, are capable of being produced. These are partly symptoms of intestinal catarrh, consisting of abdominal pains, constipation, alternating with attacks of diarrhoea, perverse appetite, and boulimia, abdominal pains of a cramp-like nature, followed by emaciation, headache, sleeplessness, pallor, lassitude, and in part nervous symptoms—epileptiform attacks without loss of consciousness, weakness of memory, melancholia, irregular febrile attacks (Lutz706). Possibly, too, Hymenolepis nana infects the urinary organs, producing true chyluria (Predtetschensky707). Stoerk and Haendel are inclined to think that this species, unlike other Cestodes parasitic in man and domestic animals, needs no intermediate host for its development, and that the larval forms (cysticercoid) live in the same host as the adults. The diagnosis is based on the demonstration of ova in the stools. As far as expulsion of this Cestode is concerned, santonin, kamala, kousso flowers and thymol appear to have no effect of importance; whilst extract of male fern, recommended by Grassi708 as a result of his considerable and successful experience, has been given, with the result that the worms really are expelled, and that after the treatment neither worms nor ova are any longer demonstrable in the stools of patients. In his cases of chyluria Predtetschensky prescribed ol. terebinth. 20 drops three times daily for a fortnight, then acid. gallic. 0·5grm. three times a day for two days, then 1·0grm. three times a day; the urine became clear, but whether permanent cure resulted remained doubtful.

Hymenolepis diminuta, H. lanceolata, Davainea asiatica, and D. madagascarensis possess no actual clinical interest; with regard to the latter it need only be pointed out that Bordier709 in studying a case of chyluria found this species in the kidneys of a person in Madagascar.

TÆnia solium.

TÆnia solium inhabits the small intestine of man; single proglottides or whole worms may get into the abdominal cavity and the bladder through fistulÆ, and penetrating the abdominal wall escape outwards or become discharged with the urine. Symptoms of intestinal stenosis are certainly very rare, as in the case recorded by Steinhaus710 of a child, aged 9, the stenosis ceasing after the expulsion of the segments. The usual position of the worm in the small intestine is with the head closely adherent to the mucosa and the proglottides lying along the intestine; from time to time portions are discharged with the fÆces per rectum. Its position can also be reversed, and the proglottides in the gut become thus discharged by vomiting.

The diagnosis depends upon the proglottides being generally discharged in pieces in the stools, or eventually an examination for eggs. Larval infection (Cysticercus cellulosÆ) occurs also in man through auto-infection or through food.

Cysticercus cellulosÆ of the skin and subcutaneous tissue occurs very seldom singly; as a rule they are found in hundreds and thousands in the same individual. They occur in different parts of the body, especially on the flexor surfaces of the extremities (generally symmetrically), small globular swellings, the size of a pea or a hazel nut, smooth, of a tough cartilaginous consistence, fairly movable under the skin, in the muscles less so. They never degenerate or cause the surrounding skin to lose its colour. It is an interesting fact that in the case described by Posselt711 nodules on the face, namely in the neighbourhood of the left cheek and behind the left ear, reformed. The following are, according to Posselt, characteristic for cutaneous tumours due to cysticerci: (1) the position in the subcutaneous connective tissue (and almost always simultaneously in the muscles); (2) the approximately equal size and regularly rounded oval form; (3) the peculiar density, almost reminding one of cartilage in its hardness and the sensation of tightly distended thick-walled bladders; (4) proportionately slight mobility; (5) with painlessness, absence of any cutaneous reaction (hyperÆmia or swelling of the skin or pigmentation). The very gradual appearance generally of the tumours supports the diagnosis, and in addition to this evidence we may emphasize the preponderating liability of the upper part of the body to attack and the symmetrical arrangement of the nodules. Cutaneous and muscular cysticerci cause the most varied symptoms, sensory disturbances, abnormal sensations, depression and a feeling of weariness whenever the diseased parts are moved, weakness in the lower extremities, pains in the course of the sciatic nerve, in addition to those which simulate cramp in the calves, numbness in the hands, pains upon their being moved. In the case of a cysticercus situated in the elbow-joint, painful dragging sensation in the course of the ulnar nerve persisted. In other cases the arm was almost paralysed, or it could not be completely extended; stiffness and bending of the little finger were noticed. Cysticerci of the gluteal muscle cause trouble upon sitting and upon defÆcation. Remittent unilateral headaches were present in the case of a cysticercus of the region of the right eyebrow; pains of a neuralgic character radiated from the diseased temporal region. The cysts may be inflamed and may suppurate; this especially happens in the case of solitary cutaneous and muscle cysticerci. The best treatment consists in puncture of the cysts with a Pravaz syringe and subsequent injection of a drop of 1 per cent. sublimate solution. Tincture of iodine has similarly been proposed (Wolff712). Frangenheim713 recommends early extirpation (this, however, only in the case of solitary cysts). Pelagutti714 believes that in his case diminution in the size of the cysts was obtained by the use of anthelminthic remedies continued over a long period combined with potassium iodide and calcium salts (internally). Cysticercus is very rarely found in the tongue; there the worms generally lie in front of the sulcus terminalis, corresponding to the middle of the tongue, according to Glas.715 In the case recorded by Gaetano716 (a boy, aged 10) there was a nodule on the left side of the tongue which grew very rapidly till it reached the size of a nut; it was embedded in the muscle and covered over by normal mucosa. Cysticerci are just as rare in the pleurÆ, in the lungs, in the intestinal submucosa, in the submucosa of the small intestine, in the mesenteric glands, in the liver, pancreas, spleen and kidneys, in the mamma, in the heart, in the bones and in the great vessels (Huber717). Cysticercus of the eye deserves special mention; in rare cases the cysticercus has been met with in the subcutaneous cellular tissue of the eyelid, once in the muscle bundles of the musculus orbicularis. Subconjunctival cysts are found chiefly in youthful individuals. Their position is most varied, generally in the neighbourhood of the inner angle of the eye. Dilated vessels pass right over the cysts, which are generally movable, together with the base they rest upon, producing a spherical protrusion. The head of the worm can sometimes be seen shining through as a whitish speck. The only symptoms are those of a slight irritation of the connective tissue and some difficulty in closing the lid; larger cysts dislocate the globe. The diagnosis has the rapid growth of the cystic tumour to support it; there is the possibility of its being mistaken for a foreign body (Kaldrovils718). After division of the connective tissue capsule extraction is easily performed. It is most rare for the cysticercus to occur in the orbit. Suppuration of the cyst may have serious consequences for the eye. It is only exceptionally that the cysticerci gain access to the anterior chamber of the eye.

Subretinal cysticerci or those localized in the vitreous are more frequent. Upon examination with the ophthalmoscope there is seen in the vitreous a bluish bladder with a smooth surface. The head is seen as a white patch, and the circle of hooks and the suckers also come into view, also the frequent movements which the head and neck make in the vitreous. Operation generally yields good results; in rare instances the globe is atrophied and must be enucleated.

Formerly cysticerci in the brain were met with in fair frequency, but the number of such cases has generally decreased of late years in a remarkable way, in correspondence with the diminution of cysticerci, which is to be attributed to compulsory meat inspection. Whilst, for example, the post-mortem records of the Pathological Institute in Berlin before the year 1875 showed 20 per cent. cysticerci affecting the brain, this number declined later to 16·3 per cent., and of late years has fallen to 1 per cent. (Orth719). Nevertheless even now cysticercus still plays no inconsiderable part in the etiology of cerebral diseases. For example, in the clinic of de Amicis at Naples, among seven cases of cysticerci of the skin, they were found four times also in the brain (Sipari720). Cysticerci may occur in the dura mater, arachnoid, pia mater, choroid plexus, the surface of the cerebral hemisphere, the medullary substance, the ventricles, the aqueduct, the corpus striatum, corpora quadrigemina, the pineal gland, the pons, the cerebellum, the olfactory trigone, the bulb, the medulla oblongata, and the olive. They are most frequently found in the cortical substance and in the ventricles; the frequency of the latter situation may be explained by the flow of the fluid (Henneberg721). The severity of the symptoms is not always in proportion to the number of cysticerci. Cases have been known in which ten, twenty and forty cysticerci have been found (Hagen-Thorn722), and yet the clinical symptoms have been remarkably slight. On the other hand, solitary cysts may both run a course completely without symptoms and also cause the severest symptoms when located in specially important parts of the brain (crus, pons, central convolutions). In the case mentioned by Jacobson723 the invasion of the brain by cysticerci was immense; the largest cyst was found in the cerebral cortex. The chief symptoms of cysticercus of the brain substance consist in the onset of cortical epilepsy, which sometimes runs a very pernicious course, frequently with psychical disturbances, whilst paralyses are absent. Perhaps, too, the localization of pain, spontaneous and on pressure, corresponding with the points observed on the cranium, is of importance. Cysticerci may also change their position in the brain; patients who had earlier suffered from epileptiform convulsions later showed intra-ocular cysticerci after the cerebral symptoms had completely disappeared. Treatment can only be surgical; v. Bergmann724 operated in two cases with well-marked improvement. Parasites in the ventricles are especially dangerous, more especially so when free in the ventricles, and so capable of giving rise to the danger of sudden closure of the foramen of Majendie (Simmonds,725 VersÉ726). Stern727 states the symptoms of cysticercus in the fourth ventricle to be the following: general cerebral pressure symptoms (headache, vertigo, vomiting, somnolence, congested disc caused by internal hydrocephalus); in addition, there are symptoms which point to disease of the hind-brain—pain and stiffness in the neck, vertigo and cerebellar ataxy, violent and persistent vomiting, slowness of pulse; and lastly those rare but certain symptoms of a lesion of the bulb, such as diabetes, respiratory disturbances and paralysis of cerebral nerves, especially of the abducens. These are far less marked than the general symptoms of cerebral pressure. One characteristic is the remarkable alternation between severe general symptoms and periods of complete sense of well-being; in this way a functional nervous affection may be simulated (Jolasse728). Brun’s symptom (in the widest sense, sudden onset of violent cerebral symptoms upon change of head-posture) is a specially characteristic sign of free cysticercus in the fourth ventricle; the disease generally terminates with sudden death from cessation of the heart’s action. Defects in motor power, convulsions, implication of other nerves, are rare and unessential complications (Hartmann729). Carefully carried out, lumbar puncture may possess some diagnostic and therapeutic value. Treatment is purely symptomatic, or eventually Neisser’s ventricle puncture may be considered.

At the base of the brain the cysticerci, as a rule, assume that form which is designated as C. racemosus, and consists of rows of delicate grape-like bladders in groups, sometimes also markedly branched, but generally sterile, which develop in the meshes of the soft meninges and may envelop the nerves and vessels of the base of the brain. Such tumours bring about hydrocephalus and chronic leptomeningitis, which must be regarded as the causes of the clinical disturbances (cysticercus meningitis), attacks of loss of consciousness, dementia and apathy, dulness and confusion and headaches. In the case recorded by Meyer730 symptoms which resembled paralysis agitans were noteworthy, and defects in speech in the case recorded by Durst731 (C. racemosus in the region of the left Sylvian fossa). According to Markwald732 C. racemosus of the fourth ventricle is said to represent a characteristic clinical picture: violent headaches, attacks of vertigo followed very soon by deep coma and death in a few days. Treatment in Cysticercus racemosus is ineffectual. In the diagnosis of cerebral cysticerci in general the recognition of multiple cysticerci in the skin and muscle and of the tapeworm is of importance. In cases of cerebral diseases in which cysticerci may be a possible cause, Remmert733 recommends that the skin of the whole body should be palpated.

Cysticercus in the spinal cord and in the vertebral column is occasionally observed; as a rule, other organs, above all the brain and its membranes, are simultaneously affected. Here, too, the cysticercus occurs in two forms—sometimes the cysts are roundish or oval, solitary or multiple, and at other times Cysticercus racemosus occurs.

TÆnia saginata.

Occurs in the small intestine of man. It is characteristic of the habit of life of this parasite that once it has become mature its proglottides are dropped off daily in increasing numbers because its growth is extraordinarily rapid. The joints are discharged generally spontaneously during the whole day without a stool. An extraordinarily unpleasant sensation is produced by the damp, cool joints slipping down into one’s lower garments and over one’s legs when walking; women especially, in whom the proglottides slip through their petticoats on to their legs, complain bitterly of this troublesome symptom. Another unpleasant symptom is superadded in the shape of the proglottides tickling the rectum, and this excites irritable people to the last degree. Different species of tapeworms are not mutually exclusive. B. latus and T. solium frequently occur side by side, so also T. solium and T. saginata—for instance, in a butcher’s assistant we once expelled twelve T. solium and one T. saginata at the same time. The greatest number of TÆniÆ which have been observed at one time amounted to forty T. solium (Kleefeld734). Even though the cysticercus of T. saginata is not, as in the case of T. solium, particularly dangerous to man, a parasite, nevertheless, which requires so much nutrient material during its rapid growth, and thereby sets up manifold disturbances in the general condition of health, ought to be expelled as rapidly and thoroughly as possible.

Tapeworms are found not uncommonly with other intestinal parasites, such as Ascaris, Oxyuris, Trichocephalus or Ancylostoma. Prunac735 described a case in which a woman passed a TÆnia through the anus while she vomited a Fasciola hepatica.

The symptomatology of these three large species of Cestodes, Dibothriocephalus latus, TÆnia solium, and T. saginata, may very well be summarized together, as, apart from some peculiarities, the clinical symptoms, especially so far as their localization in the intestine is concerned, are practically the same for all three species. In a large number of cases the hosts have no suspicion whatever that they are harbouring a tapeworm; they feel quite well and free from any disquieting symptoms whatever, and only become aware of the fact that they are the carriers of a tapeworm when the discharge of the segments takes place; on the other hand, it is often difficult to rid people of the idea that they are harbouring a TÆnia (KÜchenmeister calls such TÆnia imaginata); usually it is undigested fibrous shreds of beefsteak which are regarded by the patients as proglottides of tÆniÆ.

In a large number of cases, disturbances of the intestinal tract set in, e.g., sense of pressure in the abdomen, which sometimes becomes constant on one and the same side, or sometimes changes, now at the umbilicus and again at the epigastrium; here and there colicky pains are present. Derangements of appetite and digestion are frequently complained of; the most frequent are the sensations of morbid hunger or irregular appetite, nausea and vomiting. Thus, at the Third Congress of Internal Medicine, Senator recorded a case in which there were symptoms of nervous dyspepsia, cured after a successful vermifuge. There is either constipation or diarrhoea, so that many of such patients are brought for treatment with the diagnosis of “chronic intestinal catarrh” and correspondingly treated. As to the treatment of toxic action of the TÆniÆ when such arises, see the special section on the subject (bothriocephalus anÆmia, p.644). The frequent disturbances of the general condition, so-called reflex phenomena, so far as the action of toxic substances is not in question, may be explained by the fact of their occurrence in specially sensitive individuals who are affected by such phenomena. The proof that a diseased condition is produced by a tapeworm will be forthcoming with some degree of certainty if the symptoms cease immediately after the removal of the parasites. As a whole series of troubles, which certainly have nothing to do with them, are erroneously ascribed to the tapeworm, as is frequently assumed, one will do well to be somewhat critical in this respect.

The treatment is of a threefold nature: prophylactic, symptomatic and radical.

Under any circumstances, the best prophylaxis is that which consists in only eating the flesh of those animals in which any of the three larval forms occur (pig, cattle, salmon, pike, burbot, etc.) so prepared that the larval forms have been destroyed and the food thus rendered innocuous. For domestic and public use the rule prescribed by KÜchenmeister is under all circumstances most easily understood, namely to roast or boil till the flesh appear greyish-white and sufficiently done by reason of the coagulation of the albumen and decolorization of the blood. The general prophylaxis simply concerns the tapeworm carriers trying to limit as far as possible the further extension of the parasites in the animal world by carefully rendering the expelled segments and worms harmless (pouring sulphuric acid over the fÆces and burning the worms) and also by strictly adhering to official regulations. The official system of meat inspection in this respect has been of immense service, and much can still be done by means of thorough official control over cleanliness in abattoirs and butchers’ shops. Galli-Valerio736 very rightly desires the abolition of the custom of manuring fruit-plants such as strawberries, vegetables and salad with the contents of privies, and would extend the use of privies in the country.

Symptomatic treatment consists, in the case of those TÆniÆ which resist radical attempts at expulsion, of repeated use of drugs injurious to the worm as soon as ever new proglottides are formed, or in special cases, as in the case of persons weakened by diseases or operations, or frail old people, or patients with severe heart failure, gastric or intestinal carcinoma, or in pregnancy, in effecting the expulsion of a large chain of proglottides by the mildest measures possible.

Radical treatment of the TÆnia is not always equally easy in all three species, even when the means used are the same; the easiest to expel is T. solium, then D. latus, and the most difficult T. saginata. That as yet no certain cure exists for Cestodes is clear from the large number of drugs recommended from time to time, and the increase of bungling treatment in this respect; in addition, there is no department in which there is so much quackery as in vermifuges. The treatment proper should always be preceded by thorough preparatory treatment, the purpose of which is to render the gut as empty as possible once for all, and on the other hand to put the worms themselves into a diseased condition. How far the host himself has been made ill by such preliminary cures (herring, pickle, garlic, onions, preserved strawberries), many a person who has had to do with such things can recount. In the opinion of Fischer737 strict preparatory treatment appears to favour the development of toxic substances, or else it disposes to vomiting; as a rule it causes the patient far more discomfort than the treatment itself. In recent times far less weight is attached to these preparatory treatments than to carefully prepared and correctly dosed drugs; the preparation is generally limited to relieving the intestine in a simple way, the day before the treatment, of the densest fÆcal masses, by a simple aperient or water enema.

We recommend the following, which has always proved itself to be the best and simplest remedy against T. saginata. The patient takes early in the evening before the treatment nothing but a plate of soup or a glass of milk, and then takes a laxative (electuar. lenit or infus. sennÆ compos. or an enema), so that later in the evening one to two stools are passed. In this connection we fail to agree with Grawitz738 and Boas,739 who consider that at least preliminary evacuation of the intestines can be dispensed with. On the following morning the patient should take a cup of black coffee or tea without anything else, and half an hour later the vermifuge.

The best drug is extract. filicis maris Æther., which also forms the main constituent of most of the secret remedies recommended for tapeworms. Earlier mishaps with this preparation had their origin principally in insufficient dosage. Also, in addition to correct dosage, extract. filic. maris needs very careful preparation if satisfactory results are to be attained. If preparations with the trade mark “Helfenberg” or “Wohnar” are not used, but the male fern extract has been prepared by a chemist, one must make certain that the roots of the Aspidium filix-mas have been collected in May or October, and only green sappy specimens selected, and that the attached paleÆ have been separated, that they have been broken up small and ether poured over them with a little spirits of wine while quite fresh. The whole mass is to be kept in a cool place, but not too closely covered. If at any time a certain quantity is to be used, it is taken out, the ether carefully distilled in a retort till the extract has a suitable fluid consistency. Fischer attaches great importance to the direction in the Pharmacopoeia being exactly followed, to the effect that the extract is to be carefully stirred before prescribing, as the active substances undergo partial crystallization if kept for any length of time and sink to the bottom, so that the preparation has a different strength and toxicity in different layers. Of this extract 10 to 12 to 15grm. are to be taken in gelatine capsules within half an hour. We consider it unjustifiable to give greater doses than 15grm. to adults, as many cases are known in which to some extent severe toxic symptoms have followed, such as headache, sensation of giddiness, dyspnoea and cyanosis, yellow vision (xanthopsia), delirium, stupor, the most severe cramps in the extremities, rapidly fatal trismus and tetanus. The most serious are defects of vision of various kinds, which may end in amblyopia and amaurosis, with permanent blindness. A complete collection of toxicological literature up to the year 1903 is to be found in Marx’s740 Dissertation. Since that time further instances of such intoxications have been made known. Nagel741 observed them only in severe cases. O. Meyer742 lays special stress on the bad prognosis of the disturbances of vision evoked by poisoning with extract. filicis maris. Studt743 has seen two cases of optic neuritis, one with circumscribed, the other with diffuse retinal oedema. Uhthoff744 has only seen one case; in that reported by Noiszewski745 the toxic retinitis was cured; in Viereck’s746 case bilateral concentric limitation of the field of vision followed three days after taking 8·0grm. extract. filicis maris. Stuelp747 attributes the amaurosis occurring after taking filix mas to a toxic action on the muscularis of the central retinal artery; there followed paralysis of the vessel, vascular engorgement, and thereby nutritional defects of the nervous elements followed. In children one has to diminish the dose correspondingly, as with them, still more so than with adults, severe disturbances arise. Huber748 claims that this drug should not be given to children indiscriminately. The view is frequently expressed that a combination of extractum filicis maris with fatty oils in which the active constituents are soluble favours intoxication. Marx749 also argues from this standpoint and assumes that the ideal preparation, free from objection, would be got if from filix-mas extract a preparation free from fatty oils could be made, and he considers it advisable to limit the use of castor oil as an aperient before and after taking the “cure” and to prescribe instead a saline laxative, such as Epsom salts or Glauber’s salts. Sonnenschein750 also advises against the simultaneous exhibition of extractum filicis maris with oleum ricini, as is the case with Helfenberg’s capsules, and Boas751 is likewise anxious that ol. ricini should be avoided. Lenhartz752 appears to consider the warning against the simultaneous combination of the extract with fats or ethereal oils, and especially against the employment of castor oil as an after-treatment, as without justification, and we, too, in the course of our many filix treatments, have never yet witnessed any unfavourable effect from the use of castor oil in the after-treatment. The surest way of obviating the toxic effects of extractum filicis is to give a laxative (ol. ricini) as soon as the extract has left the stomach, say, about half an hour, so that it need not stay longer than necessary in the gut and become absorbed. Perhaps in most cases of poisoning, transgressions against this rule have been the cause of the toxic action. The nausea that sets in the day after taking the drug and the inclination to vomit are best resisted by giving iced coffee, iced tea, iced pills, peppermint tea, cognac, one to two wafer powders of menthol and sacch. lactis aa 0·2grm. (Apolant753) half an hour before the drug is taken. Fischer754 considers that lying still in the horizontal position is the best remedy. Boas755 recommends the injection of the drug into the stomachs of patients who tolerate extractum filicis badly, in the form of a thin emulsion (with gi. arab.). In the case of children the extract is prescribed with honey as an electuary. The method recommended by Fowler756 is without doubt too detailed; he prescribes before the treatment two to three to four days’ rest in bed; special diet, tablets of cascara sagrada three times daily, on the fourth day senna infusion, and then to give the extractum filicis maris in capsules in four doses, to be taken every quarter of an hour.

Under Jaquet’s757 direction, Kraft has prepared an amorphous acid from the fern root extract which is designated filmaron. As a vermifuge the drug is prescribed for children of 2 to 5 years of age in doses up to 0·2 to 0·3grm., for children of from 8 to 12 years in doses up to 0·5 to 0·7grm., and for adults up to 0·7 to 1·0grm., so as to expel the parasites. Bodenstein758 gives the filmaron oil introduced into commerce by the firm of Boehringer (one part filmaron and nine parts castor oil) in still greater dosage, either fasting or, in the case of sensitive patients, one hour after a cup of tea; he gives peppermint tablets against possible nausea. Brieger759 tested the preparation in twenty-three cases; in twenty-one of these he prescribed it as an ether-castor oil mixture, and in two as capsules. The action always took effect in from two to five hours, and only in three cases were unpleasant after-effects in the shape of colic observed; in sixteen cases the result was positive, in seven negative.

The attempts made by Goldmann760 to prepare from the bark of Musenna abyssinica, a plant of the order MyrsinaceÆ, indigenous to Persia, the active substance, namely sebirol, have shown that when this is given alone it certainly acts as a vermicide, but not as a vermifuge; on the other hand, the results of a combination of sebirol with thymol and salicylates were surprisingly good; this mixture has been introduced into commerce as tÆniol, in the shape of pastilles prepared with chocolate for children. The method of giving tÆniol is as follows: On the day before the administration a light diet and thorough purging with calomel are ordered; and then on the day of the treatment itself, after a breakfast consisting of a cup of tea, in the case of adults, thirteen to fifteen tÆniol pastilles are taken in some red wine at intervals of ten minutes respectively. In the middle of this treatment an interval of some hours is interposed. After the pastilles have been taken a calomel purge is again given. The results obtained by Liermberger761 are sufficiently encouraging to be put to further test.

Fischer762 has tested in some of his cases extracts of some new species of fern root; he employed the extract from the rhizomes of Aspidium spinulosum and A. dilatatum, two fern roots indigenous to Sweden, and obtained remarkable results (doses of 4grm.). LaurÉn763 had previously recorded similar results, and recently Friedjung,764 using extr. aspid. spinulos.

Cortex radicis granati as fresh bark is a very good drug, and is usually given as a decoction: 180·0 bark to 1,000·0 water, boiled for forty hours to 240·0, and a small cupful to be given every half an hour; colic, vomiting and diarrhoea, are, however, easily induced. The chief constituent of the granate root, pelletierinum, possesses vermicidal properties, and is much recommended, especially in France. SequelÆ easily arise (vertigo, hazy vision, malaise, vomiting, quickened heart’s action, muscular tremors, cramps in the calves), especially in delicate persons and children, so that one should refrain from giving it to the latter especially (Drivon765). Sometimes, judging by the experience of Sobotta766 and Boas,767 the action is problematical. Where it is desired to employ it in the case of adults, the following is prescribed: pellet. sulfur. 0·3 to 0·4grm., acid. tannic. 0·5grm., sir. rub. jd. 30·0grm., to be taken at one time, and a quarter to half an hour after a purgative (senna infusion). In the case of children it is better to employ semina cucurbitÆ maximÆ instead of extractum filicis maris. Sixty to 100 pumpkin seeds are pounded up with sugar, which yield a pleasant-tasting electuary, and which are taken all at once; half an hour afterwards a laxative is taken (Storch,768 Pick769), Jungklauss’s preparation is nothing else than a pumpkin extract; its action is favourable; it is, however, too expensive (Ritter770). Flores kousso up to 15 to 20grm. in compressed form or in sugar or honey in the form of electuaries (children 2·0 to 10·0grm. according to age) is not to be relied upon; kussin, prepared from kousso flowers (Bedall, Munich), is not a pure body; when taken it is divided into four parts up to 1·0 to 2·0grm. with elÆosaccharum menthÆ, at half-hourly intervals; it is said to be less unpleasant than treatment with flores kousso (Liebreich and Langgard771). Kosinum crystallisatum (dose 1·5 to 2·0grm.) is prepared by the firm of Merck. Kamala is the least potent of the tapeworm drugs in use, and is principally to be recommended in the treatment of children: 1·5 to 3·0grm. in electuaries. According to Leichtenstern772 and White773 chloroform, even in toxic doses, cannot do any harm to the tapeworm, nevertheless it has been recently recommended by CarratÚ774; chloroform 6·0, sirup. 60·0, one teaspoonful to be taken every hour (fasting). Salol is recommended by Galli-Valerio775 as an absolutely harmless tapeworm drug; thymotal (a derivative of thymol) by Pool,776 3grm. to be given up to three to four times on four consecutive days.

The drug well known long ago, cuprum oxyd. nigr., has been recently brought into fresh notice by DÖrr.777 It is also the chief constituent of the tapeworm drug introduced into commerce by the firm of Dehlsen (Itzehoe) (Koch778). The coconut is absolutely ineffectual, also naphthalin, croton-chloral, ether, gallanol, strontium lactate, glycerine and bromide of potash.

Where possible one should endeavour to discover the head or the heads of the tapeworm in the stools, so as to make certain whether the treatment has been successful; this search is best carried out by immediately and carefully pouring water over the total quantity of evacuations collected in the night stool, without stirring them up, till only the tapeworm is found lying at the bottom of the vessel.

NEMATODES.

Strongyloides stercoralis.

The pathological significance of this intestinal parasite is not yet fully demonstrated. In Seifert’s779 observation, on what Leichtenstern780 called the celebrated WÜrzburg case, the patient had suffered many times from attacks of blood-stained diarrhoea with tenesmus, as in Zinn’s781 case of a three year old boy who had bloody purulent diarrhoea. SchlÜter782 speaks of a hÆmorrhagic enteritis produced by Strongyloides. In other cases besides diarrhoea (either with or without blood) there were noted: pains in the body (SchlÜter), tenderness of the abdomen, loss of appetite, gastric troubles of a general kind, headache, giddiness, fainting attacks, anÆmia (Silvestri,783 Valdes,784 and Trappe785), so that even if in isolated cases (FÜlleborn786) symptoms are absent, some significance cannot be denied these parasites as a matter of course (Bruns,787 Leichtenstern788). According to Kurlow,789 in Siberia there is a form of sporadic bloody diarrhoea which has its origin in the presence of Strongyloides stercoralis. The parasite does not live only in the intestinal lumen, but also in the intestinal wall, where it causes abscesses, fistulÆ and effusions of blood.

Diagnosis is easily made by the detection of the actively moving larvÆ in the stools.

Treatment is rather difficult, as it is not always successful in getting rid of the parasites. Authors differ as to the effectiveness of extr. fil. maris. Goldmann790 still considers this preparation as the most effective; he recommends preliminary treatment with calomel 0·2grm. and tuber. jalapÆ 0·5grm. a day before the special treatment, which consists of gelatine capsules of 15·0grm. extr. fil. maris (to be taken in the course of four hours); afterwards rectified oil of turpentine in gelatine capsules. The thymol treatment (vide Ancylostomiasis, p. 682), thymol alone or in combination with calomel (SchlÜter,791 Valdes,792 Soussino,793 Goldmann794), has often caused diminution of the number of larvÆ, but also often remains resultless. Teissier795 maintains that by degrees he procured complete cure by the administration of mercury in the form of blue pill. In our case neither thymol nor calomel, santonin, extr. fil. maris, decoct, rad. granat., had any result whatever. Davaine796 believes he attained decrease and final disappearance of the larvÆ by protracted milk-cure. Santonin, tannalbin and other preparations seem ineffectual. Tannin enemata (Mildner797), high injections with starch enemata (SchlÜter798), may alleviate in persistent diarrhoea. Travellers who are visiting regions the native home of Strongyloides must exercise the most extreme care and scrupulous cleanliness, and these are also necessary in patients already suffering from Strongyloides, to prevent auto-reinfection (Trappe799).

Dracunculus medinensis (Dracontiasis).

The guinea worm develops in the dermis of human beings without any symptoms; only when it is completely grown does it form boil-like, extremely painful abscesses, in the greater majority of cases in the legs, in the region of the ankle, and is accompanied by general disturbance and a feeling of heaviness, dragging and pricking of the affected part; it occurs more rarely in the arms, certain parts of the back, the head, neck, scrotum and penis; in a superficial position the worm can occasionally be felt through the skin. In most cases there is only one worm and one abscess, but here and there one finds patients with three, four or even up to eight worms, and very exceptionally still more, as in the cases described by PoupÉe-Desportes800 (fifty worms) and by Harington801 (seventeen worms).

Diagnosis offers no difficulty when the worms are presenting or can be felt under the skin.

The inhabitants of the native home of the guinea worm, as a rule, quietly wait till it has got so far out that it can be conveniently grasped; it is then bound round with thread and fastened between the tips of a split piece of wood and slowly wound out. In ten to twelve days it can be wound out in this way. Emily802 makes injections of a 1 in 1,000 solution of sublimate either in the neighbourhood of the worm or directly into its body. Mense803 managed to remove the worm in one sitting by laying a wad of cotton wool soaked in chloroform on the exposed portion, thus stupefying it. Our therapeutic observations (Frangenheim804) favour the free laying open of the existing abscess and the consequent complete extraction of the worm.

Prophylaxis depends on care in the use of water in the guinea worm countries, especially dangerous being permanent waters infested by Cyclops sp.

Filaria bancrofti.

The parasitism of this filaria leads to the formation of lymphangitis, elephantiasis, chyluria, orchitis, chylocele, abscesses, lymphatic varices, perhaps also to chylous ascites and chylous diarrhoea.

Lymphangitis usually attacks the extremities, beginning generally with a rigor and swelling of the lymphatic vessels with adjoining lymph glands. The lymphatics become hard, knotty and extremely painful, the overlying skin red and swollen in longitudinal lines (Looss), high fever sets in with, to some extent, severe general disturbance. After some days the attack subsides, the swelling then partially disappears, but not completely, and often abscesses develop in consequence of the lymphangitis. Children, as a rule, suffer from such lymphangitic attacks (Finucane805).

Diagnosis is not easy, for many other causes frequently produce lymphangitis.

Treatment consists in rest, raising the affected limb, applications of vinegar and alum or liquor plumbi, in some cases incisions into the swollen part under antiseptic precautions.

Elephantiasis (Arabian) is usually situated in the lower extremities, in men in the scrotum and penis, in women in the labium pudendi, mons veneris, and the mammÆ; more rarely it attacks the upper extremities or, indeed, the head. The disease develops during repeated attacks, which occur at irregular intervals of weeks, months or years, of fever accompanied by symptoms of lymphangitis and erysipelas (elephantoid fever), and especially as the result of different accidental occurrences such as chills, bodily exertions, external irritation. The extremities become shapeless, heavy cylinders, the scrotum occasionally a colossal tumour, the female genitalia and the mammÆ smaller or larger tumours; the penis often shares in the general thickening, the inguinal glands form large hard prominent masses, and enormous deformity is caused. The cause is more often seen in men than women, rarely in children over 10, never in younger children.

Treatment of elephantiasis of the extremities consists in raising the affected part, massage, bandaging, vapour baths; the large elephantoid tumours of the genitalia and mammÆ can only be treated by operative removal.

Chyluria (hÆmato-chyluria), as a rule, begins by a series of attacks and often ceases for weeks or months, the attacks being accompanied by fever, pain in the back and lumbar region, about the kidneys and in the perinÆum. The attacks are separated by intervals of months’ or even years’ duration, a continuous chyluria being quite rare. The disease may last many years without the constitution being markedly weakened, but in other cases anÆmia and debility ensue and result in death from marasmus. In chyluria the urine becomes completely opaque like milk; but sometimes, from the presence of blood, is of a peach-like redness: the sediment contains clotted blood, and microscopically one finds fine dust-like fat granules and red cells and leucocytes, and usually, but not always, filaria larvÆ. Sclerodermia may possibly be caused by Filaria (Bancroft806).

Treatment, consists in administration of ol. santali, methylene blue (0·12grm. dose several times daily), ichthyol (in pills from 0·5 to 1·5grm. per day), ol. terebinthinÆ (0·5 to 1·5gr. per day), thymol (Ziemann807 had no result from either thymol or methylene blue), together with absolute rest in bed, diminution of all fatty nourishment and administration of light purgatives.

Orchitis is in acute attacks a relatively frequent symptom in the East; the chylocele is rarely marked; the fluid usually shows numerous larvÆ; in the case of abscesses they are generally caused directly by the adult parasites, as they have often been found in them; varices of the lymphatic vessels are either superficial or deep; lymphorrhagia arises from rupture of the dilated vessels; chylous ascites and chylous diarrhoea may also be produced by FilariÆ.

Loa loa.

Loa loa, according to modern investigations, is a parasite of the subcutaneous connective tissue of man, and its appearance in the conjunctiva somewhat accidental; in earlier times it seems to have been less common (Ziemann808). A number of cases are seen in Europe of patients who have lived in filaria regions, and on return have been found to have this Nematode in the subconjunctival tissue. Pick,809 in the case of a man who had lived in the Cameroons, found the parasites in active motion under the connective tissue of the eyeball right over the cornea; extraction was easy. Ziemann810 noted three cases of Loa loa in the eye accompanied by temporary migratory swellings in different parts of the body. In one case, observed by Wurtz and Cleri811 (a woman from the French Congo), Loa loa was the cause of intermittent elastic swellings in the subcutaneous and subconjunctival tissue (marked eosinophilia). In the case recorded by Pollack812 (for thirty years police commissioner in the Cameroons) the worm under the connective tissue of the left eye by its snake-like movements caused an unpleasant itching. With cocaine and adrenalin the worm can be made visible, and by means of a strabismus hook can be drawn out of a small wound in the connective tissue. Martens813 exhibited a Filaria extracted from the eyelid under local anÆsthesia.

Trichuris trichiura.

Whilst many authors consider the whip-worm as a harmless parasite of the large intestine (Leichtenstern,814 Eichhorst,815 Askanazy816), the number of severe and even fatal cases of diseases caused by it (trichocephaliasis) increase so much that the Trichuris trichiura must be excluded from the group of harmless intestinal parasites. (For disturbances of the nervous system and of the blood [anÆmia] from trichocephaliasis, see p.650). Infection in human beings results from the eggs that have developed outside the body, which probably reach the digestive tract on the hands soiled with dirt or earth, or possibly through drinking water. (Moosbrugger817 and Kahane818 mention in their cases that the children had an absolute passion for earth-eating.) Possibly, too, patients reinfect themselves anew, as an intermediate host is not necessary.

The anterior part of the body of the parasite is usually fixed in the mucous membrane, and according to Askanazy feeds on the blood of its host. Moosbrugger,817 Schulze,819 Kahane,818 Vix,820 Girard821 and Blanchard822 all found changes in the mucous membrane of the gut, showing that the parasites had been in the gut for a considerable time. Kahane818 had an opportunity of seeing at the Pasteur Institute Trichocephali with the anterior part of the body penetrating not only the mucosa but also deep into the muscularis of the gut wall. From this mode of attachment to the wall it is easily understood how Trichocephali, especially when they are numerous in the gut, cause local irritation and inflammatory conditions consisting of frequent attacks of diarrhoea, sometimes twenty times a day, lasting for months, resisting all remedies, and often accompanied by colicky pains and symptoms of peritonitis. The stools often have blood mixed with the fluid, very glassy, jelly-like mucus, more or less abundantly as in the cases of Moesasca, Moosbrugger,817 Kahane,818 Girard,821 Poledne,823 and Rippe.824 Nausea and vomiting are rarer symptoms.

Diagnosis as a rule can only be made by microscopical examination of the stools; together with the eggs, regular and beautifully formed Charcot-Leyden crystals occur.

The prognosis is unfavourable in severe infections, in slighter cases, where only a few worms are present, the danger of important symptoms is less. Treatment consists in administration per os of vermicides and in local treatment of the large gut. A remedy which was once much used was calomel, which is much lauded by Gibson and given as follows: calomel 0·06grm., rheum. 0·3grm., tinct. ferri sesquichlor. 1·2c.c., aq. dest. 90·0grm., six dessert-spoonfuls three times daily. Rippe appears to have got no result from the use of this prescription. Thymol, especially in conjunction with local treatment of the large intestine, had unquestionably some effect in certain cases, such as those of Girard, Poledne, Hausmann, Kahane and Schiller. The local treatment of the large bowel is most effectual when high injections of water and benzine are given. Becker825 obviously used too much benzine (1 dessert-spoonful to 1 litre of water), for severe irritation was set up, whilst Peiper826 used only a few drops of benzine, 5 drops to 1 litre of water being enough (Schiller). Instead of benzine enemata, garlic, 1 per cent. thymol solution, and physiological saline injections have been used, but the benzine enemata seem to be far and away the most effective. In Schiller’s case 2,000 worms came away on the first day as the result of such a combined treatment (thymol internally and benzine enemata).

Trichinella spiralis.

Trichinosis is, happily, becoming so much rarer that many doctors get no opportunity, either in their student days or in private practice, of seeing this severe disease; we ourselves remember having observed one typical case of a peasant, aged 17, from Metz in Med.-Rat Merkel’s clinic in Nuremberg in the year 1879. In the description of the disease we follow Merkel’s827 observations.

The eating of flesh containing TrichinÆ is often followed, if not invariably so, by gastric disturbances of different kinds, especially by vomiting and diarrhoea, with colic, great muscular fatigue, oedema of the eyelids, muscular swellings with hardness and extreme painfulness, disturbance of ocular movements, of deglutition and of breathing, hoarseness, aphonia, intestinal hÆmorrhage, bleeding of the nose, ecchymosis of the skin and mucosÆ, prurigo, herpes, miliaria, pustules, boils, severe sweating, oedema of the extremities, and, finally, desquamation of the skin; more rarely there is considerable decubitus, bronchial catarrh, hypostatic and catarrhal pneumonia, with dry and purulent pleurisy, and in severe cases symptoms of collapse with delirium close the scene. Slight cases last from three to six weeks, severe ones for several months, and in the latter convalescence is very slow. It is remarkable that in cases of trichinosis of long duration, cancer of the breast was observed at the same time (Klopsch,828 Langenbeck,829 Babes830). Death during epidemics occurred in 30 per cent. of all cases. The disease begins generally from one to ten days after eating trichinous flesh, yet there have been cases noted in which the disease began several weeks after.

Diagnosis in the presence of several cases, or in epidemics, is not difficult, but in isolated cases, on the other hand, it is not easy. If there is a suspicion of trichinosis, from the muscular fatigue and the oedema of the eyelids, the diagnosis can be made by excision of a piece of muscle and by finding the TrichinÆ in the tissue, taken with the results of the examination of the previously eaten sausage or meat. In contradistinction to this circumstantial process, there is the examination of the blood, which, according to Schleip831 (Homburg trichinosis epidemic, August 19 to 26, 1903, 130 cases), is the most valuable method of diagnosing trichinosis when the TrichinÆ have not yet penetrated the muscles, for a blood examination shows a large increase in the numbers of the eosinophile cells; StÄubli detected his seven cases in this way, four of the severe ones showing a marked hyperleucocytosis, and a combination of Kernig’s sign with absence of the patellar reflex. On account of the rarity of these two signs in combination in other infective diseases, they have a certain diagnostic value. StÄubli832 also observed in trichinosis the constant appearance of a remarkably strong positive diazo-reaction of the urine.

Prophylaxis in trichinosis is fully considered under Trichinella spiralis (p.429).

Treatment consists in those cases where it is known that trichinous flesh has been swallowed in the first place of washing out the stomach, but still more in a thorough evacuation of the bowels, for which calomel (0·5grm.), ol. ricini (a dessert-spoonful till the action becomes marked), infusion of senna with sulphate of magnesia and large enemata are employed, and should be repeated at intervals during the first few weeks. Alcohol (cognac up to 250c.c. a day) is recommended by some, also glycerine (150grm. at a dose) and large doses of dilute hydrochloric acid. Beside these, a large number of other remedies are recommended, of which, perhaps, benzine and thymol, especially in the form of enemata, are worthy of notice.

When the disease is fully developed the treatment should be symptomatic; a protracted practically continuous luke-warm bath is especially useful.

Eustrongylus gigas.

Eustrongylus gigas is most frequently found in the pelvis of the kidney. Infection in the majority of cases leads to pyelitis. The inflammation extends to the capsule from the pelvis, resulting in a purulent nephritis. In infections of longer duration, the affected kidneys become changed into so-called kidney sacs, while the kidney itself continuously shrinks. Owing to the worm fixing its posterior end in the ureter, and owing to an inflammatory swelling of the mucosa of the ureter, the passage of urine becomes very difficult.

The symptoms resemble those caused by a foreign body, e.g., kidney pain, suppression of urine, dysuria, discharge of blood and pus with the urine. But these symptoms are not sufficient for a diagnosis; this can only be established by finding eggs or the parasite itself in the urine.

Moscato833 records a case with chyluria, pain in the region of the right kidney, and hysterical symptoms. During an hysterical attack a specimen of Eustrongylus gigas was discharged in the urine, and the chyluria and nervous affections disappeared. In a case described by Stuertz834 of an Australian with chyluria due to Eustrongylus gigas the chyluria had existed for seven years. In the urine the eggs of Eustrongylus gigas were found. The cystoscopic examination showed that turbid urine was discharging from the left ureter. Nephrectomy was considered.

Ancylostoma duodenale (Ancylostomiasis).

Whilst up to quite modern times it has been generally maintained that the great majority of worm diseases cause more or less marked symptoms, the exact investigations of the last few years have made it plain that the great majority of people with worms are not only perfectly healthy, but the most careful clinical observations show no single sign of any ill-effect of the intestinal parasites on the health of the host (LÖbker and Bruns835). If infection has led to the development of only a few ancylostomes, then injury to the general health is, as a rule, scarcely noticeable. In order to produce severe illness the presence of several hundred worms in the intestine is necessary, and in general the intensity of illness varies in exact proportion to the number of worms. Then the duration of the infection comes into play: the longer the human organism is submitted to the injurious effect of the parasite, the clearer is the effect on the host. Besides, the resistance of the individual has to be considered. Whilst a more robust person can harbour without ill-effect for a longer time a larger number of ancylostomes, the symptoms of the disease become more markedly and much sooner apparent in weakly persons or in those weakened by other diseases.

The first symptom is disturbance of the digestive system; more often there is a feeling of pain in the epigastrium, more severe upon pressure, heartburn, nausea, vomiting of mucus or food at different times of the day (occasionally ancylostome ova have been found in the vomit). Whether the eggs which reach the frontal sinus with the vomit can develop into larvÆ there is questionable, but the records of v. Ziemssen836 and Huppertz,837 to the effect that in some instances ancylostomes have been discharged from the frontal sinus, are of interest. The five cases recorded by the latter had a fatal termination from oedematous swellings of the face with severe inflammation of the meninges. The tongue is furred, and extensive catarrhal stomatitis and ptyalism are recorded. The appetite is variable, increasing or diminishing, there is loathing of nourishment or a marked longing for acid food and unripe fruit, whilst ordinary meals are rejected. At first there is often constipation, later diarrhoea with abundant mucus, and often blood in the stools; microscopically eggs and Charcot-Leyden crystals were found.

In the further course of the disease symptoms due to increasing anÆmia predominate; the hÆmoglobin of the blood diminishes from one-fourth to one-fifth of the normal (Baravalle838), the eosinophile cells increase considerably (Boycott,839 Lohr840), yet in regard to diagnosis eosinophilia cannot be regarded as of equal value to a microscopical examination of the fÆces (Bruns, Liefmann, and Meckel841). The disturbances of the circulatory system take the form of more or less severe palpitation, pain in the region of the heart, quick pulse, oedema of the eyelids, of the face, of the lower limbs, and even of the whole body. Disturbance of the sexual functions (impotence, irregular menstruation, delayed onset of puberty) are not infrequently observed.

Infection in human beings takes place by the mouth, if uncleansed vegetables are eaten—in Japan especially, where human fÆces are used—and articles of food are not sufficiently carefully cleaned (Inouye842), or from putting food into the mouth with dirty hands. Looss843 does not think that drinking water is dangerous as a rule, for the larvÆ sink to the bottom in standing water, and are only brought to the top by shaking. Looss has done most valuable service by discovering that infection can arise also through the skin. During the last few years so many authors have confirmed this at first doubted source of infection, that one must accept this source of infection now, even though it is undecided which mode of infection is the more prevalent, by the mouth or through the skin. Some authors have described the changes induced in the skin by the penetration of the larvÆ; for instance, Looss and Schaudinn,844 itching papules in their own skin, and Dieminger845 a skin affection in the Graf Schwerin mine which was called the “Schweriner itch,” and a skin affection not unlike scabies in the tea plantations of Assam and South America; pani-ghao (water itch) (Dubreuilh846); the penetration of the larvÆ through the skin also explains the frequent appearance of boils and itching purulent eczema in miners in infected pits (Goldmann847).

The absolute diagnosis of ancylostomiasis depends on the detection of the ancylostome eggs in the fÆces, and presents no difficulties.

Prophylaxis is of the greatest importance, especially to miners. The spread of ancylostomiasis seems to depend only on fÆces deposited in damp places, so that on the one hand the deposition of fÆces must be prevented, and on the other the fÆces must be rendered as far as possible harmless; in addition, there is the individual prophylaxis.

General prophylaxis requires:—

(1) Examination immediately for ancylostomes of miners seeking work and of those newly taken on five to six weeks after.

(2) Indentured workers who are infected with worms are not allowed to work underground until a medical certificate in writing is brought to the effect that they are no more infected with eggs (the same procedure applies to workmen in brick kilns) (Goldmann848).

(3) Indentured workers infected with worms must submit themselves to the prescribed treatment, and after its completion further submit their stools to three examinations at intervals of about four weeks.

(4) Special supervision of miners and brick-makers coming from the Italian frontier.

(5) Workmen must be given instructions, both by word of mouth and in writing in their mother tongue, as to the infectivity and danger of ancylostomiasis both to themselves and others.

(6) Orders are to be given as to washing, baths, and changing of clothes at the end of the work.

(7) During the hours of working in the pits, taking of food is strictly forbidden without thorough and entire washing.

(8) All privies must be so arranged that the vessels used for the reception of the excreta must not leak, must be protected by a cover, and easily transportable. The emptying of these vessels must be carried out in specially constructed impenetrable pits.

(9) DefÆcation in any other place than a privy is forbidden (alike for miners and brick-makers).

(10) The manure of horses used in the mines is to be regularly removed; possibly infection takes place in this way also. [This is impossible.—J.W.W.S.]

How far it is possible to disinfect a mine already severely infected is a matter of question; Tenholt,849 Goldmann,850 and Dieminger851 recommend washing out with freshly prepared lime water with the addition of caustic soda; Calmette852 and Manouriez853 spraying with salt water. Theoretically spraying with hot water or steam should be done every now and again for the destruction of the larvÆ (Looss854). Personal prophylaxis is partially included in the general prophylaxis in so far as it is a case of oral infection, but something more can be done for the individual to avert the danger of cutaneous infection. According to Manson855 it is advisable in the tropics to cover the naked hands and feet with green Barbados tar, and the tarred parts thickly with flour; Fabre856 recommends that miners who might come in contact with infected water should anoint the unprotected parts (hands and feet), as then the larvÆ cannot penetrate the skin; this last procedure can easily be carried out on account of its simplicity and cheapness.

Among the usual remedies for the expulsion of ancylostomes thymol certainly comes first, introduced by Bozzolo857 and since used by many other authors, partly with good and partly with less good results. The day before the beginning of treatment one should endeavour to procure a thorough evacuation of the bowels by means of calomel (Lutz,858 GrÜnberger,859 Smith860) or cascara sagrada (Mann861), only fluid food should be taken the evening before, and on the day of treatment thymol is given in a quantity of 6, 8, 10 or 15grm., in single doses of 2grm. with one or two hours’ interval, and some hours after an aperient. As a rule, one day of this treatment is not enough. (Prowe862), but one is compelled to repeat it on two consecutive days, or even oftener, with subsequent intervals of many days. Thymol is either given in wafers, gelatine capsules or mixed with sugar. Caution should be used in giving brandy at the same time or[sic] bodies which dissolve thymol (oil, fat) and thereby considerably favour its absorption. It has been shown in many cases from toxic phenomena that thymol is by no means an indifferent drug; violent burning in the stomach and alimentary canal, lowering of the temperature, shortness of breath and feeble pulse, giddiness, delirium and fainting have all been observed. Sandwith863 and Thornhill,864 as well as Leichtenstern,865 even record cases of death after the use of thymol; 4grm. thymol caused severe symptoms of poisoning in GrÜnberger’s866 case. The black colour of the urine (thymoluria) which so often sets in after the first dose is quite harmless, and is no contra-indication to the continuance of the cure. Now and again there are traces of albumin in the urine, but it is very seldom there is any severe acute inflammation of the kidneys. Thymol is contra-indicated in advanced old age and in debility, also in cases with a tendency to vomiting, in gastritis, dysentery, heart or kidney affections.

The combination recommended by Goldmann867 under the name of taeniol, already mentioned under the treatment of tapeworms, and which consists of thymol, sebirol and salicylate, appears also to render good service in the treatment of ancylostomiasis (Goldmann868 and Liermberger869).

A carbonate of thymol, thymotal, from which thymol separates off in the intestine, is given three to four times a day, in doses of 3grm. per diem (children up to 1·0grm.) on four consecutive days, and at the end of the treatment a purge (Pool,870 Bauer871); Leonardi872 speaks well of thymol essence (4·0c.c. per diem) in an emulsion with plenty of water.

The next drug for the expulsion of ancylostomes is extractum filicis maris, which is to be employed as in tapeworm treatment, but has not always had the desired result, whilst in such cases as resist the fern extract, thymol attains the desired effect (Mann873), whilst the reverse is frequently observed (GrÜnberger874). Nagel875 prescribes extr. fil. 8 to 10grm., chloroform 10 to 15 drops, syr. sennÆ 16grm.; before taking, the glass must be placed in hot water, otherwise the contents will not pour freely. Zinn876 prefers extract. filicis maris (freshly prepared) to all other drugs. Warburg877 considers the treatment with extr. fil. to be all the more certain the more thoroughly the preliminary treatment is carried out. Filmaron 0·7grm., thymol 5·0grm., chloroform 1·5grm., ol. ricini 20·0grm. gave good results after being given two to three times (Nagel878). Opinions are divided as to the combination of thymol and extractum filicis maris (Hynek,879 Stockman,880 Boycott and Haldane,881 Adams882). As regards other remedies, eucalyptus oil is well spoken of by Philips883 and Hermann884: ol. eucalypti 2·0grm., chloroform 3·0grm., ol. ricini 30·0grm., to be taken at one time or in three separate doses in the morning (on the previous evening a saline purgative). Neumann885 recommends podophyllin, to be taken twice on three consecutive days in doses of 0·035grm. Podophyllin appears to produce quite a peculiar condition of the intestinal mucosa which is very prejudicial to the Ancylostoma adhering to it. Bentley886 regards -naphthol as the best drug; after previous examination of the bowels he gives it two or three times at two-hourly intervals, in doses up to 1·0grm. (Vide also the Appendix, p.754, for other drugs.) For the treatment of the anÆmia, which often persists very obstinately, good and abundant food, iron and arsenic preparations, Levico water (Goldmann,887 Liermberger888) are suitable.

Ascaris lumbricoides (Ascariasis).

Ascaris lumbricoides is one of the most frequent parasites that occur in man, both in adults as well as in children; as a rule, indeed, it most frequently infects children of medium age. The normal situation is the small intestine; this, however, is frequently left, and the Ascarides travel into the stomach, oesophagus, pharynx, bronchi, the nasal cavities and still other regions. It is a peculiarity of the Ascarides that they are prone to glide into narrow canals; for example, Clason889 records that in the case of an idiot whose custom it was to swallow glass beads, the Ascarides showed a predilection for sticking in the beads and were passed in the fÆces. The disturbances which Ascarides occasion in the intestine itself vary; isolated species do not give rise to any symptoms at all, whereas a large number may eventually give rise to severe local symptoms, or those of a toxic or reflex nature which have been discussed in the General Section.

Among the local symptoms are the following: loss of appetite, excessive appetite, perverted sense of taste, foetid breath, sensitiveness to pressure over the abdomen, colicky pains and irregularity of the bowels. The appearance and state of health suffer; the patients, children in especial frequency, become remarkably pale; their complexions undergo rapid change, and rings of grey or bluish-brown are seen about the eyes. Children may become so reduced by this rare condition, enteritis verminosa, due to Ascarides in large numbers, that suspicion of the existence of intestinal tuberculosis arises. Emaciation to a skeleton, excessive meteorism, and evacuations of thin gruel-like stools, sometimes blood-stained, are observed in these cases. Even in the case of adults, chronic uncontrollable vomiting with severe inanition due to the Ascarides has been observed. When the Ascarides escape spontaneously per anum, they frequently cause an exceedingly troublesome irritation in the anal region (pruritus ani).

The most disagreeable symptoms and those most dangerous to life arise from the migrations of Ascarides when they invade the bile-ducts; no inconsiderable number of cases of this kind are recorded in the literature (summarized, up to the year 1901, in Sick’s890 Dissertation). Penetration post mortem (or shortly before death) of the worms into the bile-ducts cannot be considered as a rarity; the laxity of the muscular orifices easily allows of this invasion also in other directions on the part of the parasite in its escape from the body of its dead host. The occurrence of the worm in the biliary passages in the living is to be regarded as still less frequent, but nevertheless often enough according to the records in literature. Sick891 was able to collect as many as sixty-one such cases, to which he added two further fresh cases from the TÜbingen clinic, that is, from the material provided by his father. In the year 1891 Borger892 collected fifty-nine cases relating to the invasion by AscaridÆ of the bile-ducts and passages, and Dauernheim’s893 Dissertation treats of this question as well. A further case of Ascaris in the ductus choledochus (choledochotomy) is recorded by Neugebauer.894 In the case of Schupper895 (woman, aged 52), all the biliary passages were distended and filled with fourteen living AscaridÆ (perhaps as they were living they had not led to a septic infection of the biliary passages); in the case communicated by Schiller,896 an Ascaris had gained access to the biliary passages after an operation for cholelithiasis (with distension of the gall-bladder and formation of a fistula); it had kept itself alive here eighteen days and was extracted from the fistulous opening. Epstein897 confirms the correctness of the explanation of the mark of strangulation in an Ascaris in Mertens’898 case (in a woman, aged 30, there was first icterus, later ascites, anasarca, swelling of the liver, then the discharge of two dead AscaridÆ, one of which exhibited a constriction somewhat behind its centre; after that there was rapid improvement in all the symptoms); in his case there was icterus in consequence of closure of the ductus choledochus by an Ascaris. After the discharge of the worm the symptoms persisted; one of the AscaridÆ had a typical strangulation mark. From the observation recorded by Vierordt899 it follows that, without doubt, mature females can penetrate into the liver and there deposit eggs; in addition, that such eggs appear exceptionally to undergo segmentation. A unique feature in this case consisted in the exclusive discharge of immature worms almost regularly throughout an interval of nine weeks; this cannot be explained from our present knowledge of the biology and pathology of the AscaridÆ. These worms clearly make their way from the intestine outwards, through the opening into the duodenum of the common bile-duct, and unquestionably the fully developed Ascarides, with the aid of their conical head end, are enabled gradually to penetrate the wall of the ductus choledochus (Quincke900), and gain access to the gall-bladder, the hepatic duct and its branches.

The changes in the biliary passages and the liver are, on the one hand, the mechanical results of a partial or total obstruction to the flow of the bile, and, on the other, of inflammatory processes. The blocking of the common bile-duct and of the trunk of the hepatic duct leads to the well-known symptoms of biliary engorgement; protracted continuance of this condition has, as its sequela, general distension of the whole biliary system and degenerative destruction of the liver-cells. If the Ascaris is situated at some other part of the biliary system, its presence causes a partial arrest of the flow of bile, with the corresponding sequelÆ. Many Ascarides perish in the ductus choledochus, and here and in the gall-bladder they may supply the nucleus of a gall-stone; deeper in the liver this does not appear to happen; the dead AscaridÆ here undergo a kind of maceration, disintegrate, and may be completely absorbed; in many cases the worms continue to live for a very long time in the biliary passages. When the worms infect the biliary passages through the invasion of intestinal bacteria, liver abscesses arise (Dauernheim,901 Saltykow902). Leer903 goes so far as to maintain that AscaridÆ may be the second most frequent cause of liver abscesses. That Ascaris in the pancreas may simulate liver abscess in a remarkable fashion is shown by Vierordt’s904 observation, which is quite unique, while AscaridÆ have been found to occur in isolated instances in the excretory ducts of the pancreas and in its branches, where they have remained living for a long time.

It is no rare occurrence for AscaridÆ, in consequence of their migration into the stomach, to be ejected by the act of vomiting, and in such way to gain access into the upper air passages, or to find their way during sleep into the nose or accessory sinuses (Mosler and Peiper905) without giving rise to special symptoms. For example, Troja906 found in the frontal sinus of a cadaver a large coiled-up Ascaris which occupied the whole cavity. Wrisberg907 made the same observation in the cadaver of a boy. Deschamps908 and Fortessin909 mention an Ascaris being met with in the antrum of Highmore. Observations of the discharge of living or dead Ascarides from the nose are frequently recorded. To this class belongs the case mentioned by Albrecht,910 in which an Ascaris was removed from the nose of a girl, aged 7; also the case recorded by Benievini,911 from the nose of one of whose friends a worm escaped; he had suffered from the most violent headaches, fainting fits, dimness of vision and vomiting; after the escape those untoward symptoms disappeared. Similar records have been made by Forest,912 Lanzoni,913 Langelott,914 Tulpe,915 Reisel,916 Fehr,917 Bruckmann,918 Bahr,919 Slabber,920 Lange,921 and Chiari.922 A rarer case is that recorded by Haffner,923 that of a child, aged 4, in whom an Ascaris reached the nasal cavity through the act of vomiting, and from there it gained access through the naso-lachrymal duct and the inferior lachrymal sac into the lower punctum lachrymale, from which half of it protruded.

Among the rarer causes of the occurrence of strange bodies in the pharynx and naso-pharyngeal cavity, Jurasz924 mentions in the first place vomiting, which may afford opportunity for the more solid bodies of the stomach contents, and even parasites of the digestive tract, especially AscaridÆ, to become firmly lodged in the pharyngeal or naso-pharyngeal cavity. AscaridÆ may obtain access from the naso-pharyngeal cavity to the middle ear by way of the Eustachian tube, as has been observed by Reynolds925 and WagenhÄuser926; in the case recorded by Turnbull927 (girl, aged 8, with pains in her ear) the Ascaris apparently reached the external auditory meatus by the same route.

The irritation of the larynx and air passages by AscaridÆ is far more dangerous than their penetration into the nose and naso-pharyngeal cavity, because not only are attacks of suffocation, but sudden suffocation thereby induced. Oesterlein928 records a fatal attack of choking from AscaridÆ in the trachea. In a case recorded by Smyly929 of a boy, aged 3 1/2, tracheotomy for extreme asphyxia was performed without relief. At the post-mortem the cause of the asphyxia was found to be an Ascaris in the trachea. FÜrst930 collected twenty-five observations of invasion of the larynx and trachea by Ascaris. Mosler931 reports the case of a patient with aphonia and dyspnoea from whose larynx an Ascaris was removed. Donati932 reports a case of four Ascarides in the larynx, and Cerchez933 of asphyxia from Ascarides in the larynx or trachea. Wagner934 records the case of a boy, aged 8, in whom a coil of worms was ejected from the stomach by vomiting; the mass blocked the entrance to the larynx and led to death from suffocation. A case similar to that recorded by Smyly is communicated by Rabot935; it was that of a child who underwent tracheotomy for diphtheria, and who was not relieved by the operation; when, however, an Ascaris appeared in the cannula and the parasite was removed the child breathed well. In Negresco’s936 case, that of a boy, aged 3, an Ascaris gained access to the larynx and from there into the trachea, and a fatal issue from asphyxia resulted.

The route by which AscaridÆ obtain access to the urinary passages must remain undecided. SchlÜter937 treated a woman, aged 60, with retention of urine. Upon catheterization the hinder end of an Ascaris hung out from the catheter opening; the anterior end was fixed in the tube and the lumen was obstructed. Perhaps in the female sex AscaridÆ travel from the gut into the vulva and from there into the bladder, as they have already been observed in the vagina, where they cause troublesome symptoms (pruritus pudendi).

The diagnosis of ascariasis is not in general difficult; now and then the worms are discharged spontaneously; if not, the ova, which cannot be mistaken, can easily be detected in the fÆces upon microscopical examination. Epstein’s938 method—namely, on every occasion to obtain fresh material for examination—is much to be recommended. This consists in introducing a Nelaton’s catheter into the rectum with a rotatory motion and then drawing it out. A small portion of fÆces forced into the catheter opening is more than sufficient to demonstrate the presence of ova of the parasites upon microscopical examination of a preparation.

In spite of all pressure on the part of relatives, treatment directly against AscaridÆ should not be carried out until the diagnosis is certain.

As regards prophylaxis, much can be done by not throwing the worms, when expelled, on to the dung-hill or into the privy, but straightway into the fire. Metschnikoff939 has issued a warning against the consumption of unboiled or badly washed vegetables, salad, strawberries, etc., and also against drinking polluted water.

For the expulsion of the worms flores cinÆ were formerly considered the most useful means; now, however, santonic lactone—santonin—which is prepared from them, is almost universally preferred. By many, especially in practising among children, flores cinÆ are still recommended in the form of StÖrk’s worm electuary (consisting of flores cinÆ, rad. jalapÆ, valerian and oxymel simplex). Guermonprez940 recommends them because he thinks that santonin only excites the worms and consequently causes unpleasant symptoms. Besides, in the form of the above-mentioned electuary, flores cinÆ can also be given several times daily with raspberry jelly up to 0·5grm. to 2grm. (children and adults).

Santonin is prescribed either in single doses from 0·03 to 0·05 to 0·1grm. with sugar in the form of powder, or else in oily solution. When given in the latter form the absorption of the santonin in the stomach is excluded and the whole quantity introduced is thus enabled to reach the worms in the intestinal canal. KÜchenmeister941 has already recommended combination of santonin with ol. ricini. Lewin,942 however, states that ol. morrhuÆ, ol. olivarum, ol. cocos and ol. cinÆ can also be taken. In prescribing santonin in oily solution Henoch943 also prefers the combination with ol. ricini. According to Lewin’s direction the prescription would run as follows:—

If the patients should manifest a repugnance to castor oil, Starke’s ricinus paste may be selected:—

If necessary the first-mentioned mixture might be given in gelatine capsules. Small children should be given 0·025grm. santonin in warm olive oil slightly sweetened with sugar (a teaspoonful) in the morning; if in the course of the forenoon specimens of Ascaris escape, a second dose should follow in the afternoon about two hours after the meal. Older children should be given santonin in combination with castor oil or calomel:—

As santonin causes slight toxic symptoms such as urticaria, vomiting, retention of urine, headache, vertigo, yellow vision (xanthopsia), it is in every case advisable to follow with a laxative to expel the drug from the body as speedily as possible. The urine is coloured yellow from one to two days and assumes a scarlet red colour upon the addition of alkalis; this, however, soon disappears, while it persists in the case of rhubarb and senna.

In the place of santonin iodoform in the form of a powder mixed with bicarbonate of soda is given by Schidlowsky944 in doses up to 0·01 to 0·06grm. three times daily, and a dose of castor oil on the day after the iodoform is given. Thymol in addition to thymol enemas may be tried, in doses up to 0·5 to 2·0grm. per diem (Calderone,945 Hausmann946), also -naphthol up to 0·45grm. three times daily (Du Bois947), and—

(Ferran948), filmaron oil 1·0 to 2·0 to 3·0grm. in gelatine capsules, according to age (Bodenstein949). BrÜning950,951 recommends the so-called American worm-seed oil, derived from a plant native to the United States, Chenopodium anthelminticum, Gray. It is given in emulsion (ol. chenopodii anthelm. 10·0grm., vitelli ovi unius, ol. amygd., gi. arab. pulver. aa 10·0grm., aq. destill. 200grm.; f. emulsio) up to 0·25 to 0·5grm. three times daily at one to two-hourly intervals, or as a pure oil from 8 to 15 drops in sugar and water; to be followed an hour after the last dose by oleum ricini or pulvis curellÆ. If no action takes place by the afternoon, a laxative should again be given. The treatment frequently must be repeated the next day. Thelen952 appears to have had good results from this drug.

Corsican moss (mousse de Corse), kamala, Artemisia absinthium, valerian, semen sabadillÆ, have all been supplanted by santonin and at most are used as adjuvants for the latter.

Oxyuris vermicularis (Oxyuriasis).

OxyuridÆ do not remain at rest in the gut, but leave it, generally at night time, to migrate around the anus, into the gluteal folds, and in females into the vulva and vagina and still higher up, giving rise in these different sites to a whole series of irritative symptoms. In the rectum, also, OxyuridÆ give rise to such symptoms, which are manifested in the form of catarrhal inflammation; numerous chronic intestinal catarrhs are thus explained. The frequent coincidence of hÆmorrhoidal troubles with OxyuridÆ may be attributed to the fact that the veins of the rectum participate in those changes which have been described as occurring in the intestinal mucosa. OxyuridÆ may also give rise to prolapse of the anus, either by the tenesmus they bring about having such a prolapse as its direct sequel, or the proctitis that supervenes constituting a further etiological factor for its occurrence (Ungar953). Anal fistulÆ which still further increase the trouble, and even rectal fistulÆ, appear to be capable of onset in consequence of the irritation of the mucosa brought about by OxyuridÆ (Trendelenburg954). The conditions recorded by von Wagener955 and Ruffer956 appear to be of interest. At the post-mortem on a child, aged 5, the former found fifteen to twenty quite minute nodules on some Peyer’s patches, and in several of these OxyuridÆ were found upon microscopical examination between the calcareous concretions within the patches. He presumes that the parasites penetrated the follicular ulcers, and after healing of the latter that they died and became calcified. In the case of a man who died from cirrhosis of the liver, Ruffer found in the rectum, at a distance of about 6in. from the anal orifice, several tumours covered by the intestinal mucosa, the smallest of which was the size of a pin’s head and the largest that of a walnut. The tumours looked like calculi overgrown by connective tissue; under the microscope, countless OxyuridÆ ova were found in their interior.

The symptoms of irritation set up by these migrations from the intestine are troublesome to the last degree; the pruritus thereby induced is often unendurable; as this irritation from itching comes on with especial severity during the night, the night’s rest is grievously interfered with; many attacks of night terrors appear to be occasioned by these worms. But the general condition suffers as well; the children become pallid and affected with nervous excitability. Through the act of scratching the irritated parts the ova of the parasites may be conveyed by contaminated fingers directly into the oral or nasal cavities, certainly also into the oral cavity by the contamination of food (auto-infection). In the case of boys the sexual organs may be excited sympathetically through irritation of the sacral nerves of the rectum; girls may be induced to practise onanism in consequence of the entrance of the worms into the vulva.

As a result of the itching irritation which the scratching gives rise to, and of the irritation due to the parasites migrating to the area surrounding the anus, congestion and inflammatory symptoms may arise in the peri-anal and perineal regions (weeping eczema, Seifert),957 and these do not abate till after the removal of the oxyuriasis. Some authors speak of an oxyuriasis cutanea (Majochi958), in the more limited sense of a dermatitis intertriginoides. So far five such cases have been recorded, one each by Szerlecky,959 Michelson,960 Majochi,961 Barbagallo962 and Vignolo-Lutati.963 Szerlecky’s case was that of a young woman with intertrigo over the thighs (the skin was covered as if with leather); Michelson’s case was that of a boy, aged 13, with intertrigo on the skin of the genito-crural fold, of the scrotum and of the thigh; Majochi’s was that of a man, aged 38, with the same localization; Barbagallo’s case was that of a boy, aged 14, in whom the dermatitis extended to the hypogastrium (rhagades on the scrotum); and Vignolo-Lutati’s case was that of a man, aged 24, with intertrigo of the peri-anal and perineal region, of the scrotum and the inner side of the thigh.

On leaving the gut, OxyuridÆ frequently migrate to the stomach, to the oesophagus, to the mouth, to the nasopharyngeal cavity, and into the nose (Zarniko964) (the localization in the nose has been referred to as associated with the possibility of auto-infection—see p. 695 as to the development of embryos from the ova in the moist nasal mucosa). Still the occurrence of OxyuridÆ in the nose is among the greatest of rarities. Chiari965 records the case of a girl, aged 14, who suffered from pains at the root of the nose and in the left side of the forehead; female specimens of Oxyuris vermicularis were evacuated from her nose on several occasions. A similar case is recorded by Hartmann966; it was that of a girl, aged 13, with epileptiform convulsions and psychic disturbances; numerous Oxyurides frequently escaped from her nose. With their departure the symptoms of irritation of the central nervous system also disappeared. Rheins967 records a case, that of a woman, in which a specimen of Oxyuris vermicularis was discharged from the right nostril during the act of sneezing. Proskauer968 found in the nose of a woman, aged 30, a conglomerate of from fifteen to twenty very small worms which proved to be Oxyuris embryos.

The diagnosis of oxyuriasis is not difficult to make, as the troublesome sensations in the anus and about the genitals necessarily suggest the presence of OxyuridÆ. As a rule the small white worms are seen crawling about over recently evacuated fÆces, or the ova are found upon microscopical examination of soiled matter adhering to the anus, or in scrapings removed with the spatula from the surface of the skin (in the case of oxyuriasis cutanea).

Prophylaxis has to be directed to infection with Oxyurides generally, on the one hand, and, on the other, to the possibility of auto-infection. With reference to the first-mentioned point, Metschnikoff’s969 directions should be borne in mind, to the effect that badly washed vegetables, salad, etc., ought not to be eaten (vegetables to be rinsed with boiling water), and also that the members of the family of the diseased individual should be examined for OxyuridÆ and eventually be treated (Heller970). With regard to the second point, one has to observe strict cleanliness in general (Barbagallo971 found ova of the parasites in the layer of dirt under the finger-nails).

Treatment of oxyuriasis must be of a twofold nature; first, medicinal, the administration per os of vermicidal drugs in combination with purgatives; and secondly, local treatment of the gut by means of enemata, suppositories and high injections. Following the method prescribed by Ungar,972 pulv. glycyrrhizÆ co. is first given in the case of smaller children, castor oil or calomel in that of those older, in order to evacuate the intestine, and four times daily on two days following one another a dose of naphthalin, not directly after meal-time, but as far as possible in the interval between two meals, and at the same time the ingestion of fatty or oily nutriment is as far as possible to be avoided. After eight days this treatment should be repeated, and under certain circumstances once again after a further interval of a fortnight. The dose varies between 0·05 and 0·1grm. (children of 1 year old), 0·1 to 0·2grm. (children of 2 to 3 years old) and 0·2 to 0·4grm. (children of 4 to 10 years old). DornblÜth973 employs the same medicament in a form only slightly modified from Ungar’s method, Barbagallo974 gives internally only a purgative (decoct. sennÆ cum natr. sulfur). Thymol, santonin, kousso, kamala or valerian may be tried instead of naphthalin. For enemata the following are employed: naphthalin in a solution of 1 in 50, ol. olivar. or thymol 0·1 in 200 aq. destill., diluted solutions of lysol, menthol in 1/2 per cent. oily solution, salicylate of soda in watery solution, decoctum tannaceti with santonin, with the addition of some drops of ol. terebinth. (Barbagallo). Decoctions of garlic, infusion of valerian, sulphur water (sublimate is to be avoided), aq. calcariÆ, ol. olivarum camphoratum (Vignolo-Lutati). Santonin 0·1grm. is the best to employ for suppositories.

For high injections, large quantities of plain water are employed (2 to 4 litres), or soapy water (0·2 to 0·5 per cent. solution of sapo medicatus, Heller,975 Still976), 1/2 per cent. salicylic acid solution or liq. alum. acet. (one tablespoonful to a litre of water, DornblÜth977), or gujanosol (2 to 3 to 4 to 5 per cent. solution, Rahn978). The employment of benzine for such high injections is not advisable according to the experience of Senger,979 owing to the symptoms of poisoning after the external application of benzine, at least not in the case of young children.

That diseases of the intestine which are accompanied by frequent thin fluid evacuations may lead to recovery from oxyuriasis has frequently been observed by us in the case of young children who have suffered from dysentery (Seifert980). Inunctions of cod-liver oil appear to be very valuable in the treatment of oxyuriasis (Szerlecky, Vignolo-Lutati), whilst those with mercurial ointment may easily increase the inflammatory symptoms. The luxury recommended by Esser,981 that patients every evening before going to sleep should have the female OxyuridÆ picked from the anal fold in the knee-elbow position is one which is certainly only in the power of a few people to carry into execution.

HIRUDINEI (Leeches).

The only one of the leeches that comes under consideration from the clinical point of view is Limnatis nilotica (HÆmopsis sanguisuga), which obtains access to the mouth with drinking water, and becomes lodged, even in the case of man, in the pharynx, larynx, trachea, oesophagus and nose.

Amongst the causes of severe hÆmorrhage from the pharynx Jurasz982 mentions the occurrence of leeches in that region: in Northern Europe this must be accounted one of the greatest of rarities, whilst at all times in southern countries, such as South Italy, Spain, Greece, Algiers, Tunis and Egypt, it appears to have been more frequent. Even the physicians of antiquity had much to say about it. Upon the occurrence of blood-stained expectoration, Hippocrates recommends the oral cavity to be examined to see whether a leech is not present in it. Galen speaks of hÆmatemesis due to the presence of leeches in the pharynx and stomach. Similar mention is found in the writings of Celsus, Asclepiades, Scribonius Largus, Dioscorides, AËtius, Oribasius, Paulus Aegineta and others. In recent times, Cortial983 has published observations relating to this subject which he had the opportunity of making in Constantine. Palazzolo984 also in Sicily found leeches in two cases in the pharynx, in one case on the posterior wall, in the other in the crypt over the left tonsil. According to Roset,985 leeches adhere by preference behind the uvula, simulating hÆmatemesis and hÆmoptysis, and the persistent hÆmorrhages they give rise to may lead to severe anÆmia. Leeches are found in still greater frequency in the larynx than in the pharyngeal cavity. Huber986 records several observations of this kind in his historical and therapeutical study. In the case of a man, aged 64, Ramon de la Sota y Lastra987 observed a leech on the nodulus epiglottidis; this was removed with the forceps. In the case recorded by Photiades,988 a leech had remained adherent to the vocal cord for more than twenty-two days. Maissurianz989 records two such cases: in one the leech had remained in the sinus morgagni for three weeks, in the other in the same place for ten days. The case recorded by Schmolitschew990 is an interesting one; it was that of a woman who for four days had suffered from violent hÆmoptysis, the cause of which was a leech that was fixed on the laryngeal wall of the epiglottis close above the vocal cords. In his case (that of a soldier), Godet991 was forced to perform thyrotomy to remove the leech from the larynx. Ficano992 removed a live leech with the forceps from the lower laryngeal cavity in a man, aged 30. Massei993 reports a similar case. The case reported by Winternitz and Karbinski994 was that of a peasant girl, aged 16, who suffered from coughing, hoarseness, and blood-stained expectoration; a leech had lodged on the root of the epiglottis. Aubert995 removed a leech from the larynx of a woman after the performance of tracheotomy. Seifert996 reports three cases: in the first the leech had become fixed to the left vocal cord, in the second it was found in the lower laryngeal cavity, and in the third on the border of the left ligamentum aryepiglotticum. Leone997 has published the case of a leech in the larynx, Martin998 two cases with the leech lodged in the lower laryngeal cavity, Berthoud999 a similar case, Palazzolo1000 two such cases, Panzat1001 one case (lower laryngeal cavity). Moucharinski1002 reports a case in which the leech had stayed more than twenty days in the larynx. Martin1003 easily removed a leech from the posterior portion of the vocal cord with the forceps. Vieus and Nepeon1004 record a case of a leech in the larynx. It is quite exceptional for leeches to gain access to the trachea; cases of this kind have been recorded by Aubert,1005 Vicano,1006 Ridola1007 and Tapin1008 (the leech was firmly fixed to the bifurcation and caused coughing, hÆmoptysis and attacks of asphyxia; it was easily removed by the aid of a tracheal tube). Now and then leeches are found in the nose.

Lusitanus1009 relates the case of a man who suffered from severe headaches. A medical man ordered the application of a leech to the anterior portion of the nostril. Owing to the carelessness of the surgeon the leech crawled right into the nose; it was impossible to extract the leech or to kill it, and it produced a severe hÆmorrhage which led to the death of the patient within two days. In a case recorded by Sinclair,1010 a leech, HÆmopsis sanguisuga, gained access to the nose of a boy, aged 3; it remained there a fortnight; it caused frequent attacks of epistaxis and in the end it was removed by means of forceps. Condorelli-Francaviglia1011 records a case in which severe epistaxis was caused by a leech which had probably entered the anterior portion of the left nostril by way of the pharynx and become tightly fixed there. It was seen by posterior rhinoscopy, and was removed from in front by means of slightly curved forceps. Sota y Lastra1012 mentions the occurrence of leeches in the nose, and Keng1013 reports the case of nasal obstruction from a leech. The removal of leeches is effected by means of injections or by the direct sprinkling of salt or acid solutions on their bodies, which brings about their detachment. When possible a previous attempt should be made to seize them with forceps so as to make their immediate extraction possible. The species of HÆmadipsa (Looss1014) live in tropical regions in moist places on the ground or in the jungle. They climb bushes and even trees with astonishing rapidity upon the approach of larger animals and also of man (whom they clearly recognize from the vibration of the ground caused by footsteps). From thence they let themselves fall on their victims to suck their blood. Their bites are generally painless, and of themselves not dangerous, but if they are unusually numerous they rapidly accumulate on the body in large numbers and give rise to marked debility and, if the wound become infected, to severe complications and even death. On the other hand, under careful treatment the wounds heal easily and fairly rapidly.

Firm leather and firmly adhering clothes afford no certain protection against the attacks of these leeches, as they know how to force themselves with extraordinary rapidity through the narrowest interstices between the clothes and thus gain access to the skin. When they have sucked their fill—and this may take several hours to accomplish—they fall off of themselves. To effect an earlier removal drops of irritative or corrosive fluids are employed (salt solutions, acids, etc.). Tearing away the leech by force should be avoided, as in this way portions of the leech’s body may be left behind in the wound and inflammation be set up.

ARTHROPODA.

Leptus autumnalis (Grass, Harvest, or Gooseberry Mite1015).

In the hot season of the year, that is, during the months of July and August, it is noticed that those people who stray amongst syringa bushes or who pick gooseberries or kidney beans are attacked by the Leptus autumnalis. On the uncovered parts of the body there appear numerous red spots and papules, which itch and burn smartly. The itching does not commence diffusely, as in the case of scabies (MacLennars1016), but is limited to the particular points where the parasite is situated. There are especial outbreaks of itching in the morning, arising perhaps from the hatching of ova in the host after lying in the warmth of the bed.1017 Leptus frequently provokes general erythema, eczematization or severe feverish urticaria, which in France is known by the name of fiÈvre de grain (MÉgnieu, Besnier1018). If the individual efflorescences be carefully examined, there will be noticed almost without exception a minute boss towards the centre, noticeable by its yellowish-red colour. If an attempt is made to remove it with the point of a needle or to scrape it off the surface, one can often perceive, even with the naked eye, a small reddish creature moving actively about. The treatment of these very troublesome symptoms consists in warm baths with soapy lavages, also lavages with alcohol, spirit salmiac (G.P.), 5 per cent. carbol or creolin solution, diluted vinegar, benzine, emulsions of balsam of Peru, rubbing in sulphur ointment (Sandwith1019); ointments of creosote or eucalyptus are recommended. Other grass and grain mites also occasionally penetrate the skin of man and produce transitory but sometimes very severe eruptions, urticaria and eczema papulosum, as Geber1020 and subsequent to him Josai1021 have reported of the barley mite. In sensitive individuals the skin becomes bright red, to a greater or less extent their temperature is raised and frequently slight febrile affections are present. If the inflammatory skin symptoms have reached their culminating point after three or four days and no fresh complications arise, they only remain for a short while, the effects of scratching and pigment spots being left.

Kedani, Akaneesch (The Japanese River or Inundation Disease).

This disease is only known in Japan, and is limited to the neighbourhood of some great rivers on the west coast. The people mostly attacked are those who cut the hemp harvest in the infected localities, occasionally those who transport it or come into contact with it (Looss1022). The disease is frequently manifested in the form of indefinite disturbances of the general condition; it commences generally on the sixth day after the presumed infection with rigors, headaches, feeling of weakness, swelling of the lymphatic glands in the loin or in the arm-pits; in the periphery a black dry scab is formed. In addition there is an intense conjunctivitis, and added to symptoms of fever an exanthema resembling measles that lasts from four to seven days. There is frequent delirium and difficulty of hearing which persist for a long while. Obstinate constipation is a striking symptom. At the end of a fortnight, earlier in slighter cases, the fever commences to abate and a rapid convalescence sets in. In pregnant women abortion with fatal issue is frequent. With regard to prophylaxis, Baelz1023 recommends as rapid a cultivation of the soil as possible, which has led to a speedy disappearance of the disease in districts where it was once dreaded. Treatment is symptomatic. Japanese do not tolerate antipyretic drugs as well as Europeans.

Dermanyssus gallinÆ (avium).

During the day the resort of bird mites is in the droppings and in the woodwork, etc., of cages in which canaries, crossbills and parrots are kept; in the crevices of doors, in the chinks between the board planks of bedsteads, so that at night they may seek some domestic animal to suck the blood and so satisfy their hunger. It is by no means rare for young animals, chickens and unfledged pigeons, etc., to perish in consequence of the great loss of blood. This nocturnal habit of life explains why no mites can be found during the day in spite of the most careful examination of the human body, to which they may be transmitted. On the uncovered parts of the body they not only cause severe irritation, but also severe diffuse itching erythema and eczema. Thorough disinfection of the cages by hot solution of caustic potash, in addition, sprinkling over with tar, red carbolic acid or petroleum, thoroughly powdering over the birds with flores pyrethrÆ, washing with water containing oleum anisi, washing the walls, doors and bedsteads with soap, disinfection of the mattresses, linen and clothes, will protect against further infection. In the case of man the disease needs no special treatment, as the eruptions generally disappear after some days. Heinecke1024 recommends lavages with 1 per cent. carbolic acid solution. [Vide also p.492 in body of this work.—F.V.T.]

[Dermanyssus hirundinis, Hermann, is identical with this species. By far the best treatment is with paraffin or kerosene oil applied to the places where they pass the day.—F.V.T.]

Ixodes reduvius (ricinus).

The female is occasionally transmitted to the human skin, and bores its proboscis deep into it and sucks itself full of blood. At sensitive points of the cutaneous surface—for example over the skin of the penis—a feeling of severe pain is produced. Buy’s1025 observations as to the geographical distribution of the IxodinÆ show that in all lands in which cattle, horses, sheep and dogs exist, IxodinÆ are to be found. Recent observations show that the IxodinÆ play an important part in the transmission of HÆmosporidia (vide body of work, pp. 493, 494). Sprinkling with oil, vaseline, benzine, ether, petroleum, naphtha, turpentine (Jelgenum1026), will easily lead to the removal of the parasite; if the body is torn away with violence and the proboscis is left sticking in the skin, the presence of the latter will give rise to inflammation and suppuration.

Sarcoptes scabiei (Scabies).

The disease produced by Sarcoptes scabiei shows itself in polymorphous areas, such as accompany eczema, and are produced on the one hand by the Sarcoptes alone and on the other hand by the scratching with the nails. The localization of both kinds of efflorescences is different from those which are produced by the Sarcoptes; they occur as papules, vesicles, pustules and mite-tracks, and their usual situation is between the fingers, on the ulnar border of the hand, on the wrist, on the palm of the hand, on the anterior border of the axilla, on the penis and at the base of the thorax. The excoriations are situated on the forearm, over the thigh, over the abdomen, and may be distributed in greater or less degree over the whole body; the back and the face only remain free. The symptoms consist in violent itching, the onset of which specially takes place at night.

The mite-tracks are fine curving lines, curved like a, u, c, or s, which appear as if they had been scratched with a fine needle. Upon closer examination with the magnifying glass one sees in their course small openings. These openings, in persons who keep themselves clean, are scarcely coloured; but in patients whose occupations necessitate their being associated with coloured or dirty substances, they are dark. The length of the tracks varies from some millimetres to 1 1/2 to 2cm. They are at the one end, where the Sarcoptes is embedded in the epidermis, widened like a funnel and slightly exfoliated. The track at this point is sharply defined; the mite shows through the epidermis as a yellowish round point. In the course of the track there develop papulÆ, vesicles or pustules, which raise the level of the track. The intensity of these inflammatory appearances depends upon the susceptibility of the human individual and upon the capability of the reaction of the skin. There are people in whom scarcely any inflammatory symptoms make their appearance; on the other hand there are some, especially children and lymphatic individuals, in whom severe impetiginous ecthymatous pustules, together with their sequelÆ, are set up.

The results produced by scratching consist in papules, which usually bear a small scab of blood, and are arranged in the form of striÆ, in eczematous surfaces, weeping or sanguineous scabs, vesicles, pustules, etc. The complications that set in are frequently urticaria and even furuncles, lymphangitis and inflammation of the glands, which now and then is followed by the formation of abscesses in the glands.

The duration of the disease is unlimited; when untreated it leads to a form of rare occurrence, that of scabies norvegica1027; in this the collection of crusts and scales, in which a quantity of dead mites, larvÆ and ova are present, may become colossal.

The symptoms of scabies abate in the presence of intercurrent acute diseases and reappear after the malady is over. The fact has for long contributed to the idea of scabies being regarded as a disease capable of being “driven in” upon the internal organs and forming metastases.

The diagnosis is rendered certain upon the discovery of a track. Traces of scratching on the extremities and on the abdomen, papular or pustular efflorescences between the fingers, toes, in the neighbourhood of the wrist, of the elbow, on the anterior border of the arm-pit, on the tuber ischii, in the girdle region, and especially the presence of disintegrated tracts over the penis (prepuce and glans), will allow of the diagnosis being made. Certain occupational eczemas (grocers, lime-workers, maltsters, bakers and others), also prurigo, must be borne in mind when diagnosing this disease.

The prognosis is always a favourable one. Even after such a long duration and after such severe symptoms the disease may completely clear up. There are, however, frequently left behind post-scabious inflammatous and pruriginous conditions which only yield after protracted treatment. Scabiophilia, which persists in certain patients for a long time after the scabies has been cured, must here be mentioned.

In the treatment of scabies four points must be kept in view. (1) The mites and the ova must be killed by the treatment; (2) the treatment must have regard to the intensity of the inflammatory symptoms; (3) the clothes (body-linen) of the patients must be disinfected; the bed-linen, the beds and the bedsteads must be cleansed; (4) when a person suffers from scabies his entourage must be examined, and all diseased conditions treated in the same way as under (3).

The treatment (1) should be preceded by a bath with thorough soap ablution, and when the inflammatory symptoms are not too severe, with green soap. After the bath the skin is dried and the scabies remedy proper applied in warmth. Sulphur preparations receive first consideration; among such Vlemingkz’s mixture occupies a prominent position; this is rubbed in for half an hour by means of a strong camel-hair brush, to be followed by another bath and powder applications after drying. Repeat this method for three days one after the other, or for two days, and a third time eight days later. The latter method is worthy of recommendation as the ova, which perhaps resist the parasiticide action, have by this time developed into larvÆ, and the latter can then be destroyed with certainty. The remaining sulphur preparations, which are specially employed in the form of ointments, are more complex, as the ointment should remain on the skin. Helmerisch’s and Wilkinson’s ointments are the kinds specially employed. Nagelschmidt1028 recommends thiopinol as a very suitable sulphur preparation in the form of baths or as a 10 or 5 per cent. ointment in the following way: Upon his reception the patient is given a thiopinol bath, in which he remains for thirty minutes. Immediately afterwards 30 to 40grm. 10 per cent. thiopinol vaseline is carefully rubbed in. The rubbing is repeated daily, and the treatment is concluded on the second to fourth day with a second thiopinol bath. Thiopinol produces no more irritation than the ordinary sulphur ointments; it is, however, much more penetrative and more capable of absorption.

We frequently make use of Kaposi’s naphthol ointment, as it renders the skin supple, causes proportionately little irritation, and has but little smell. Treatment with balsam of Peru is certainly expensive, but in the slighter attacks it is relatively the simplest. We give the patient a bath, have him thoroughly dried and rub in 30 to 40 to 50grm. balsam of Peru carefully and evenly all over, wrap him in a covering of wool, and make him rest in bed for twelve to fifteen hours, to be followed by a bath with careful cleansing with soap; this treatment need rarely be repeated. The balsam of Peru can be applied undiluted for the rubbings or mixed with ung. glycerini, or resorbin or glycerine in equal parts. [Norman Walker uses balsam of Peru 1/2oz. dissolved in rectified spirit; to be painted on with a brush.]—J.P.S. The manufacturers name the undiluted product of the active constituent of balsam of Peru, benzoic acid benzyl-ester, Peruscabin. For the treatment of scabies it is recommended by Sachs1029 that it should only be administered when mixed with ricinus oil, under the name of Peru oil, in applications repeated three times within thirty-six hours.

Sack1030 also considers Peru oil a non-irritant, effectual, pleasant, inodorous and non-staining drug. But he only allows the applications to be used every twelve hours for three to four consecutive days (altogether 200 to 300grm. of Peru oil are requisite), and after the sixth or seventh rubbing a bath should be taken with the use of Dutch soap. Juliusberg1031 considers this treatment specially suited for private practice. Another modern drug is epicarin ([Beta]-oxy-naphthyl-ortho-oxy-meta-tolyol acid); this is applied in 10 to 20 per cent. ointments (Pfeiffenberger1032), epicarin 7·0grm., cretÆ alb. 2·0grm., vasel. flavi 30·0grm., lanolin 15·0grm., axungia poric. 45·0grm. (Rille1033); epicarin 15·0grm., sapon. virid. 5·0grm., axung. poric. 100·0grm., cretÆ alb. 10·0grm. (Kraus1034); for children, epicarin 5·0grm., lanolin 90·0grm., ol. olivar. 10·0grm. (Kaposi1035). Siebert1036 lays stress upon the odourlessness and colourlessness of epicarin ointment as a strong reason for its use, and points out that it is a harmless drug, the action of which is certain. Endermol (salicylic acid ointment) has a destructive action on the mites even in a 0·1 per cent. ointment (Wolters,1037 Demitsch1038); it is, however, very expensive and not wholly free from danger; and the same applies to nicotiana soap (Taenzer,1039 Schumann1040).

To give an account in detail of the drugs and methods—old and new—used in the treatment of scabies would far outrun the limits of this work.

Demodex folliculorum.

It is not yet certain whether the Demodex folliculorum is capable of developing pathological conditions in man. Veiel1041 assumes that the hair follicle mite has no connection either with the formation of comedones or even with sebaceous gland disease. Kaposi1042 considers that they cause no disease in man and cannot be regarded as a cause of acne. Saalfeld1043 clearly adheres to the same standpoint, similarly so Jessner,1044 who, when discussing comedones, makes no mention of acne of hair follicle mites. Weyl1045 and Geber1046 adhere to the opinion that the presence of a Demodex in man in contradistinction to its presence in animals possesses absolutely no pathogenic influence. On the other hand de Amicis,1047 Majochi,1048 and Dubreuilh1049 report single cases of pronounced circumscribed clear brown pigmentations which they attribute to Demodex folliculorum. In all these cases, moreover, as regards localization the affection had a certain resemblance to pityriasis versicolor; nevertheless, in the scales separated off with the scalpel no fungi were found, but on the other hand Demodices in moderate quantity. In his earlier cases Majochi has seen the Demodex in the secretion from meibomian glands and had claimed it to be the excitant of chalazion and, as Mibelli1050 did, considered it to be the cause of some diseases of the eyelids. Ivers1051 found the parasite in 69 per cent. of normal borders of the eyelids, and attributes a pathological signification to it. HÜnsche1052 and Mulder1053 arrive at the same conclusions; in the light of their investigations the Demodex is found as a constant accessory—certainly not in the meibomian glands, as it is limited only to the internal part of the hair follicle. Lewandowsky1054 considers that it can hardly be demonstrated at present that the same parasite which in individual specimens causes no symptoms is capable of producing pathological conditions when markedly increased in numbers.

Treatment is by the removal of the comedones, above all, by their mechanical removal by pressure with a watch-key and with the various comedo-compressors, and by subsequent cleansing of the skin with ether, benzine or spirit. If the eyelids should be affected with blepharitis due to the presence of Demodex in large numbers, epilation and administration of a parasiticide is recommended.

Demodex folliculorum canis.

Transmission from dog to man is in any case very rare, and by many its occurrence is generally doubted. Nevertheless Gruby1055 and Remak1056 claim that it is transmissible—an opinion which has also been shared by Neumann1057 and ZÜrn.1058 The latter saw in the case of a married couple who had the care of mangy dogs the onset of diseased areas on their hands and feet, which were like those on the dogs and contained the same parasites.

A. Babes1059 also reports several observations which go to show that persons who, to some extent, have been shown to have been in contact with mange-stricken dogs have been attacked by a scabies-like eruption localized over the thorax, abdomen, back and extremities; large numbers of Demodices were found in the follicular pustules. Lewandowsky1060 reports one case—that of an Italian workman, who suffered from an outbreak on the face, like impetigo; there was crust formation and at the edge of the crusts the epidermis appeared like a narrow row or border of vesicles. A small portion of the covering of the row of vesicles was lifted off, and after slight warming examined in 40 per cent. liquor potassÆ. In this a large number of animal parasites of the Demodex group were found, and without doubt Demodex folliculorum canis alone. HÜnsche1061 assumes that Demodex folliculorum penetrates into the tissues and produces abscesses.

Treatment first consisted in dusting with zinc amyl powder, but after four days there was no change. After the regular use of xeroform as a powder application, the affection cleared up within fourteen days.

INSECTA.

Pediculus capitis (Pediculus capitis) (Head Louse).

We find Pediculus capitis in very young children and in others more grown up to be the incessant and frequent cause of impetiginous crust-forming eczemas. It is more frequent in girls than in boys. In families it is endemic, in schools epidemic, but it also occurs in fair frequency in female adults (servant maids, waitresses) who may pay little attention to bodily cleanliness. The puncture of the parasites sets up a severe irritation, which leads to violent scratching. The consequences of this are the formation of nodules and pustules, crusts and “weeping” patches; the hairs become felted and the final clinical picture is that of plica polonica. The conditions of irritation which are produced by these parasites and then by the scratchings of the impetiginous, and frequently the very severe suppurative processes of the hair-bed, lead to swellings in the neck and sometimes even to glandular suppurations. The eczematous processes not infrequently extend over the face, the neck and the thorax. Blepharitis and conjunctivitis may be due to Pediculus capitis.

The means of infection are often very remarkable. Transmission from one individual to another certainly often occurs, but infection may take place in railway carriages and in other ways. A case under the observation of a colleague in Frankfort is a most remarkable one: he diagnosed pediculosis as the cause of a head eczema occurring among the children of one of the best families there. The infection took place through dolls adorned with human hair, in which the presence of nits could be demonstrated.

The diagnosis of Pediculus capitis is not difficult to make when the hairs and hairy scalp are carefully examined for nits and living parasites. In better families it is a good plan to point out the corpora delicti to their possessors and to make them aware of the possible sources of infection.

As regards treatment, lotions of sabadill vinegar are recommended; in slighter cases these are quite sufficient. In severe cases cure will not result unless dressings of petroleum, naphthol ointment (5 to 10 per cent.) and balsam of Peru be applied. In the case of plica polonica, the hair must be cut quite short (even in adults) so as to control matting of the hair. To get rid of nits from hair that is not matted, careful combing and washing with strongly alkaline fluids or with hot vinegar is suitable.

Pediculus vestimenti (Clothes Louse).

The clothes louse attacks adults by preference, and with especial frequency old and emaciated persons. It lives in the clothes, but derives its nourishment from the body. At the moment at which the clothes louse inserts its proboscis into the skin the person experiences a slight sting, which, however, at once ceases to hurt. If the body of the louse is sucked full of blood it falls off and the individual has rest from it for a time. A wheal develops around the hÆmorrhagic area of the bitten spot and itches severely. The itching goes on until the eruption is scratched all over. This is followed by crust formation. When many parasites are present the itching reflexes become more severe, and the patients scratch themselves considerably and make long marks at those places where the Pediculi have been. The localization of the scratching effects is characteristic, corresponding with folds between portions of clothing (regions between the shoulder-blades, wrist and neck). If the condition lasts for a month, the scratching effects extend over the whole body, and secondary efflorescences become associated with it, such as pustules, ulcers and eczemas. Intermediate between this we find cicatrices and pigmentation, the latter under certain circumstances extending over the whole body. Sulla, Herod, Cardinal Dupet, Philip II, and others are said to have died from louse disease. That even at present many human beings are exposed to the danger of being devoured by lice is a fact that we have had the opportunity of observing on several occasions. Only to record one instance, a man, aged 65, was received into our clinic some time ago in an absolutely neglected condition (he had been staying for some weeks in a stable, lying on a wretched bed). The whole of the surface of his body was covered with countless furuncles, of greater and less size, which had partly become changed into undermined ulcers. Over the ulcers and beneath their undermined edges Pediculi were swarming.

Phthirius inguinalis (Pediculus pubis) (Crab Louse).

The transmission of these parasites generally takes place during coitus, and therefore they especially occur in the pubes. It is possible also that transmission is effected through dirty clothes and bed-linen and privy seats.1062 Starting from the pubes the animals crawl out over the other parts of the body provided with hairs to the abdominal wall and the thorax (so far as these parts are furnished with thick hair) to the arm-pits, the beard, the eyebrows; not, however, to the hair of the head, or rarely so; among our numerous cases we have never met with an example of the crab louse attacking the hair of the head.

The irritation produced by the crab louse is extraordinarily severe, especially during the night, as the warmth of the bed incites the lice to active sucking. In consequence of the violent scratching indulged in, eczemas are set up at the points attacked, and these often spread to the neighbouring parts not covered with hair.

Of special interest is the onset of maculÆ cÆruleÆ (tÂches bleues) in some persons affected with crab lice (people disposed to sweating seem to be peculiarly liable to these). They consist in pale blue patches of various size and shape, varying from that of a hemp-seed to that of a lentil, and again to that of a nail in size and form. These are found over the cutaneous surface of the abdomen, thorax and thigh, and are often only seen by a good lateral illumination. Duguet1063 considers that the condition is a toxic erythema, that it is set up, on the occasion of the bite of the parasite penetrating the skin, by the poisonous substance derived from it. Oppenheim1064 considers that it is a colouring substance that is formed in the salivary glands of the parasites, and which penetrates the skin when the insects bite, and thus forms the maculÆ cÆruleÆ. We have on several occasions emulated the experiment of Duguet (trituration in a mortar of crab lice freshly taken from the human body and inoculating the mass thus obtained beneath the skin), and have similarly been enabled to produce the maculÆ cÆruleÆ experimentally, but we have certainly been unable to determine which of the hypotheses is the correct one, the toxic erythema or the colouring substance inhibition theory.

The diagnosis of phthirasis is very easy, for either the sexually mature parasites or the nits are found on the hairs.

As regards treatment, grey ointment is regarded as a generally useful application; it gives rise, however, to a slight eczema of the genitals, especially in males, when injudiciously used. Geber1065 recommends petroleum or balsam of Peru, Oppenheim1066 a 1 per cent. sublimate solution for lotions, or a mixture of equal parts of petroleum and benzine when the sublimate cannot be borne. The use of a 5 per cent. ointment with hydrarg. oxid. flavum is worth considering in treatment of pediculosis of the eyebrows and eyelashes. The simplest method of treatment, and one with a radical effect, is that by sulphuric ether recommended by Thomer.1067 It certainly produces a sharp burning sensation, but the living parasites and nits are destroyed in one sitting. We prefer ether lotions as a rule, and we thoroughly rub the affected parts with a pad of wadding well soaked with the ether. The dead parasites and the nits fall on to what lies beneath when the rubbing is done thoroughly, and the burning sensation caused by the ether only lasts a few minutes.

Cimex (Acanthia) lectularia1068 (Cimex lectularius) (Bed Bug).

The puncture in the skin made by the bed bug gives rise to an extraordinary amount of severe itching and a burning sensation, and when the skin is sensitive wheals of remarkable size (urticaria ex cimicibus). These eruptions that cause such severe itching are scratched by those attacked, till very soon blood begins to flow, and this generally leads to the formation of a dried crust of blood at the point of eruption.

The diagnosis is not always easy, as urticaria arising in other ways frequently leads to similar vigorous scratching and formation of crusts of dried blood. Men who have some experience in this matter (for example, commercial travellers), when they are attacked by severe itching at night, are in the habit of striking a light and searching in their bed and body-linen for the bugs, in order to be able to hand over the corpora delicti to the landlord if need be. The assumption that the bugs in the East play an actual part in the propagation of tuberculosis and bubonic plague has been proved by investigations made by Nuttall1069 to be at least very exaggerated if not wholly without foundation. Further investigations may decide how far the bugs participate in the transmission of kala-azar, as is believed by Rogers to take place.

The bed bugs must be exterminated by spraying the chinks and joints in the boards with petroleum and benzine, pulling up the carpets and cleansing the bedsteads. For the treatment of the bite itself the methods recommended as an antidote against insects’ stings in general are suitable: 2 per cent. carbol vaseline (Rosenbach1070), thymol dissolved in spirit (1 in 501071), Æthrol or deci-Æthrol, form-Æthrol (manufactured by Dr. Nordlinger, FlÖrsheim a. /M.), formol1072 (formol 15 parts, xylol 5 parts, acetone 44 parts, Canada balsam 1 part), with the aid of a pad of wadding placed over the part bitten, lavages with vinegar, citron juice and spirit of salmiac.

Pulex irritans (Human Flea).

The bite of the flea produces a slight discharge of blood about the size of a pin’s head, which rapidly becomes surrounded with a circular area similar to a patch of roseola. The redness fades away after a longer or shorter while (several hours), whilst the discharge of blood is to be seen for one or two days longer. In dirty people the whole body may be covered with such discharges of blood. Individuals with very delicate, sensitive skin, especially small children, show true wheal formation at the site of the bite. In certain cases there develops from one such single bite an urticaria that extends over a large part of the body. The manner by which an irritating substance is introduced into the skin upon biting by the bed bug and also by the flea is clear. The bite is followed by a feeling of itching, which is liable to rob nervous persons of their sleep. Sensitive individuals are upset even by the fleas moving over the surface of the skin during their rest at night.

Treatment consists in extreme cleanliness, capture of the parasites, sprinkling the body and bed-linen with insect powders. The fleas are difficult to remove from barracks, schools and hospitals.

Dermatophilus (Sarcopsylla) penetrans (Sand Flea).

The fertilized females penetrate into the skin with their heads, and here they swell, in consequence of the numerous and growing eggs and larvÆ, to a white ball the size of a small pea, on which the head is recognizable only as a small brown point.

In this way a small brown tumour arises, over which, at the commencement, the skin is not reddened; after some days, however, it becomes inflamed; in the centre of it a small opening is seen. If the parasite is not extracted the skin that lies over it becomes destroyed by suppuration, and thus becomes removed. At the commencement the part affected itches, with increasing inflammation; the symptoms of irritation become more severe and may amount to actual pain. If the small suppurative processes be neglected, inflammation and gangrenous and septic processes may arise. The region of the body sought out by preference by the sand flea is the sole of the foot, the toes, under the free ends of the nails and the digito-plantoid folds—more rarely the scrotum, thigh and other parts are attacked (Scheube1073). The number of parasites found on one person may amount to several hundreds.

Treatment consists in the removal of the parasites from the skin with a needle or a small sharp knife and the application of a bandage. Rubbing the feet with copaiba or Peru balsam, sprinkling them with insect powder, or washing them with bay rum (Berger1074) acts as a prophylactic or removes the irritation of the skin produced by the parasites.

Myiasis.

Under the name of myiasis we designate the complex symptoms which parasitic dipterous larvÆ give rise to in man (Braun), and we conceive under the term myiasis externa (dermatosa s. cutanea) all lesions of the human integument caused by fly larvÆ and of the cavities covered with mucosa therewith connected, such as the external auditory meatus, the oro-nasal cavity, the urethra and vagina. The occurrence of dipterous larvÆ in the digestive tract is named myiasis intestinalia or interna.

Myiasis externa.

The larvÆ of a species of fly belonging to the MuscidÆ, Lucilia macellaria,1075 are found in relative frequency in the nose, especially in America and India.1076 Riley1077 has stated that the screw-worm of Central America and of the United States is nothing else than the larva of Lucilia macellaria, and also that the Brazilian fly named “berna” may be no other than Lucilia macellaria. Their offspring may set up inflammatory disturbances in the soft tissues of man. This fly has a wide distribution, from the Argentine Republic to Canada, also in the British portions of the East Indies, where the disease is named “peenash.” This word is derived from the Sanskrit, and is said to be a collective name for all diseases of the nose. Lahory1078 states that within a period of nine years ninety-one cases of “peenash” occurred in Allyghar, two of these ending fatally. Lucilia macellaria is not at all timid but bold, like the house-flies and blue-bottles, its relatives. It not only lives at no great distance from human dwellings, and forces its way into villas and country houses, but even attacks its victims without awaking them from their sleep. Although this species shows a certain preference for nasal cavities affected with catarrh or pus (v. Frantzius1079), and also the external auditory meatus, as well as ulcerated or wounded parts of the body, and even badly ulcerated skin carcinoma (Lutz1080), it is not a rare thing for it to penetrate into one of the above-mentioned cavities rapidly to deposit its eggs, without these parts having been previously affected. The report also of Conil,1081 in which these flies bear the name of Calliphora anthropophaga1082 is an interesting one. Probably it was the same species of Muscid in the cases of myiasis nasi observed by von Tengemann, Delasiauve,1083 Weber,1084 Mankiewicz,1085 and Kirschmann.1086 In the case recorded by Prima,1087 and in that recorded by Britton,1088 the issue was a fatal one; in the latter the larvÆ escaped through the pharynx and nose; the hyoid bone and the soft parts of the palate were destroyed, the speech and power of swallowing were hindered. At the post-mortem extensive destruction of the internal nose was found, so that the nasal bones could only be kept in their position by the aid of the external skin. Even during life 227 larvÆ escaped. Similar destructive processes were found in the case communicated by Richardson.1089 In two cases reported by Schmidt1090 300 and 350 larvÆ were respectively removed from the nose, and the patients recovered. Wolinz1091 found his patient had lost consciousness, and that in the pus filling up the entrances to the nose numerous larvÆ were moving; recovery followed. In the case communicated by Adler,1092 more than 150 larvÆ escaped from the nose of an old man. Curran1093 states that people suffering from “peenash” frequently die from meningitis. The cases reported by Pierre1094 related to the forms of severe myiasis frequently to be observed in Guiana. In a patient who was suffering from typhus (? typhoid), Douglas1095 found the conjunctival sacs full of larvÆ; in two other individuals the nasal cavities were attacked.

The case observed by Summa1096 was that of a man, aged 28, who suffered from nasal obstruction, foetor, epistaxis and pain in the nose. Out of seven of the cases occurring at Fort Clark, U.S.A., and in its neighbourhood, six ended fatally; in all these cases Kimball1097 diagnosed ozÆna; attracted by the strong odour the flies forced their way into the noses of the patients when asleep and there deposited their ova. In a case reported by CarriÈre1098 an abscess of the nasal septum was produced by the larvÆ of flies; Chiodi1099 reports seven cases of myiasis due to Lucilia macellaria; among these was a case of rhinitis myiatica, in which a cerebral abscess leading to a fatal termination developed, being produced by the migration of a larva into the brain. Among the three cases of Lesbini1100 was that of a girl, aged 16, with 250 larvÆ in the diseased nasal cavity. Quintano1101 observed larvÆ beneath the eyelids in one case. It is possible that the cases of Cesare1102 and Calamida1103 were those of myiasis nasi due to Lucilia macellaria. The larvÆ are also found in the nasal accessory sinuses, as is seen from the cases reported by De Saulle1104 (frontal sinus), Delasiauve1105 (frontal sinus), MacGregor1106 (antrum of Highmore), and Bordenave1107 (antrum of Highmore).

If a survey is made of the literature of the cases described of myiasis nasi produced by Lucilia macellaria1108 the following information is forthcoming: In Europe this form of the disease is of very rare occurrence, whilst in America and India1109 it is frequent. Persons suffering from ozÆna are rendered the most liable to danger as the penetrating odour entices the flies in tropical countries with intense frequency, so much so that v. Frantzius does not consider this myiasis as an independent disease, but as a complication of ozÆna of frequent occurrence in warm countries. The infection is so far of interest in its nature, in that it only takes place during the day. The fly is on the wing only by day when the sun is shining, and consequently only deposits its eggs at this time. Therefore persons suffering from ozÆna are principally exposed to the danger of being pursued by the flies when they succumb to sleep during the mid-day hours in the open or in dwellings that are not closed up.

Headache is the symptom which most troubles the patients. It extends over the whole cranium and persists uninterruptedly, with more or less severe periods. Violent headaches in the frontal and buccal regions are almost always present in this complaint; they are experienced either only on one side or on both simultaneously; sometimes the pain is extended to the lower jaw and region of the neck, following the whole extent of the trigeminal nerve. The inflammation of the nasal mucosa produced by the penetration into it of the larvÆ extends right into the frontal sinus and antrum. Simultaneously the patients, at the height of their trouble, suffer from persistent sleeplessness and severe vertigo, so that they reel and cannot walk straight; excessive sneezing always sets in at the commencement. The larvÆ immediately spread over the nasal mucosa to seek a place suitable to feed, and irritate the nasal mucous membrane by the tickling sensation they produce. Later the patients frequently sneeze when the maggots move to and fro.

One very characteristic symptom consists in the peculiar swelling of the face, which is extended either over the whole or only one half of it, and may alternate with attacks of erysipelas (Brokaw1110).

The discharge from the nose is of special diagnostic value. It consists of a blood-stained serous matter or blood-stained fluid, which is perpetually trickling from one or both nostrils. The larvÆ especially choose the anterior portions of the nasal cavity, where they can be seen lying in groups together at the base of the choanÆ. The consequence of this is that the soft palate becomes intensely swollen, and this in turn makes swallowing very difficult; speech is impeded, and the voice acquires a nasal intonation. Symptoms of fever become more or less pronounced according to the number of larvÆ present, and according to the nature and constitution of the individual. The appetite is in abeyance throughout the whole duration of the illness, and sometimes there is the onset of slight attacks of diarrhoea.

If the larvÆ are not removed in good time there follows excessive destruction of the interior of the nose and of the turbinals; and the whole nasal framework undergoes disintegration, frequently, too, the velum palati, so that the larvÆ come into sight in the oral cavity. Individuals thus severely attacked succumb through exhaustion, symptoms of meningitis (cerebral abscess) or septicÆmia (Prima1111). Twenty-one out of thirty-eight cases recorded (collected) by Maillard1112 died.

The method of prophylaxis is self-evident from what has been stated. On bright summer days neither the healthy nor those suffering from diseases of the nose should sleep during the day-time in the open or in public habitations; sufferers from nasal diseases should pay special attention to this.

Treatment consists in the removal of the larvÆ; this, however, is not always easy.

With regard to the methods which have proved to be effectual in the destruction of living larvÆ and their expulsion from the nose, strongly smelling and easily diluted fluids come first, such as alcohol, eau-de-Cologne, and ether, which should kill the creatures when injected into the nostrils. The earlier physicians, such as Salzmann,1113 Honold,1114 and Henkel,1115 have seen good results from the use of these methods, whilst Mankiewicz1116 and Goldstein1117 obtained no results whatever. Kimball’s1118 careful investigations have shown that a decoction of bitter herbs recommended by Behrends1119 (tansy, wormwood) have just as little effect as the tobacco decoction employed by Boerhave1120 and Kilgour.1121 The sternutatories employed by the older physicians are entirely neglected. Delasiauve1122 experienced good results from the inhalation of the smoke of paper cigarettes, which were soaked with a solution of 2·0 pot. arsenic in 30·0 distilled water. Whilst, according to Kimball, balsam of Peru had no effect on the larvÆ, Mankiewicz succeeded in removing the larvÆ from the nose with the help of that drug. Turpentine steam or mixtures of turpentine employed by Indian physicians have not been very effectual according to Moore,1123 Kimball and Goldstein. Success has been attained in some cases by the use of insufflations of calomel (Roura,1124 Cerna,1125 Schmidt1126) or of iodoform (Pascal1127). Joseph1128 recommends concentrated alum solution being sniffed up into the nose as very effectual. Sublimate and carbol solutions do not appear to be very successful (Kimball, Moore, Goldstein), whilst benzine inhalations (Pierre1129) have shown better results. Scheppegrell1130 strongly recommends injections of oil which kill the larvÆ, while it is perfectly harmless to the nasal mucosa. Cesare1131 employed nasal lavages with solutions of salicylate of soda with good results, and Calamida1132 lavages with physiological saline solution. Bresgen1133 recommends the nose being cocainized and the larvÆ being removed with a pincette. Roorda-Smit1134 cocainized the nose, then insufflated calomel and plugged the nose with a gauze tampon dusted with calomel. After two hours fifty-six larvÆ crawled out along the plug. Continuation of the treatment resulted in a complete cure.

Injections of chloroform water (Jourdran1135) or chloroform inhalations, or injections of pure chloroform into the nose, have proved the most effectual (Goldstein,1136 Osborn,1137 Jourdran, Durham,1138 Jennings,1139 Kimball,1140 Mackenzie,1141 Oatmann,1142 Zarniko,1143 Antony,1144 Folkes1145). Camphorated carbolic solutions are very well spoken of: Grayson1146 states that these kill the larvÆ immediately. Some authors have removed the larvÆ with forceps (Goldstein1147), others with pincettes; thus Brokaw extracted 200 fragments with the forceps, Pascal eighty fragments with the pincettes, and Wolinz1148 also appears to have removed the larvÆ with forceps.

Greater operative measures than these do not appear to have been undertaken in latter days; yet Morgagni1149 states that the army surgeon, CÆsar Mogatus, at Bologna, first trephined the frontal sinus and then extracted a “worm” from it.

LarvÆ of other MuscidÆ have come under observation much more rarely (Cheval1150 [larvÆ of Galleria mellonella1151], Bond,1152 Dumesnil1153 [larvÆ of Piophila casei]). Species of the genus Scolopendra (Myriapoda), which all shun the light and seek their food during the night—which consists of animal and vegetable substances—frequently make their way into the nasal cavities of people when asleep. They are found not only in the nose, but in the accessory cavities. In the chapter on the “Parasites of the Nose”1154 we have collected striking instances, but we have omitted to mention the observation made by Bertrand1155 (Scolopendra in sinus maxillaris) and that made by Bergmann1156 (Scolopendra in sinus frontalis). In the same chapter some remarks are made as to the occurrence in the nose of earwigs, caterpillars, scorpions and termites, as well as of animals which have not been identified.

The larvÆ that develop in the auditory meatus penetrate the membrana tympani, destroy the middle ear and may produce meningitis and intracranial suppurations. In one case Vesescu1157 extracted seven living larvÆ from the ear with the aid of a thin pair of pincettes. KÖhler1158 recommends the infusion of drops of ol. terebinth. to destroy the larvÆ, Quintano1159 the insufflation of the following powder: Oxid. hydrarg. rubr., sulfur., aa 1·0grm., pulv. gi. arab. 8·0grm.; Lesbini1160 recommends tincture of iodine. In the case reported by Henneberg1161 the larvÆ were those of Lucilia cÆsar.

Eye affections due to Lucilia macellaria are very uncommon; the literature relating to the lesions of the eye produced by the larvÆ of flies has been collected in Kayser’s1162 work. In the cases under the observation of Schultz-Zeyden1163 both the eyes of a female tramp were destroyed, and quantities of larvÆ were also found in the nasal fossÆ and in the ears.

The Lucilia is found relatively seldom on the cutaneous surface. Henneberg’s1164 case was that of a neglected girl, aged 20, in whom countless larvÆ (L. cÆsar) were found in a plica polonica; after the plica polonica had been removed the scalp was found to be covered with a large quantity of ulcers which swarmed with larvÆ, large and small. The skin of the trunk was also much macerated and covered with larvÆ. Death resulted from sepsis; WestenhÖffer1165 remarks on this case that a lesion of the head from which the patient had suffered previously and the perpetual state of intoxication in which she was had probably given rise to the lodgment of the fly larvÆ. Whether the communications made by Munk1166 of maggots in the mouth relate to Lucilia I do not know. Vesescu,1167 in one case with extensive ulceration and deep fistulÆ in the skin, removed 176 larvÆ with the pincette. In Roorda-Smit’s1168 case there were two ulcers in the neck of a girl, aged 17, and larvÆ appeared at their base. After dusting with calomel and the application of a bandage the next day fifty-two dead or half-dead larvÆ came to light. Recovery took place. Lesbini,1169 in the case of an old lady, saw numerous larvÆ in an ulcer of the leg she was suffering from. Hector’s1170 case appears to have been one of myiasis cutanea provoked by Lucilia.

The first exact observations of myiasis cutanea from Sarcophaga magnifica are due to Wohlfahrt,1171 in whose honour Portschinsky1172 named this species of fly S. wohlfahrti. Portschinsky ascertained that S. wohlfahrti was not confined to man as its sole host, but that several of our domestic animals, such as cattle, horses, pigs, dogs and geese, were visited. In these animals small wounds serve to entice the flies and to supply them with a suitable site for the deposition of their eggs. The oral armature of the young larvÆ renders it easy for them to penetrate not only the mucosa and cutaneous surface but also intact places in the submucous connective tissue. In many localities more than half the herds have proved to be infected by the flies. The fly only frequents open spaces and never enters human dwellings, and is so timid that it approaches man only during sleep; infection, therefore, takes place only out of doors, in summer, in clear, warm weather, and only in such individuals as sleep in the open air. Individuals are most exposed to risk who suffer from catarrhs or inflammations, combined with purulent secretions of the nasal cavity (ozÆna), or otorrhoea, or ulcers in any parts of the body accessible to the female fly.

The frequency and intensity of the infection will be in inverse proportion to the advance in civilization of the inhabitants, their idea of cleanliness, their having timely medical aid and the chances of their being rapidly attended to. On that account the majority of cases of myiasis (Sarcophaga) are reported from Russia. The literature of this kind of myiasis nasalis is not very extensive; in addition to Wohlfahrt, Portschinsky and Joseph,1173 there is a communication by GerstÄcker,1174 who found fifteen adult larvÆ of S. wohlfahrti in the nasal cavity of one man. The larvÆ transmitted from Ordruf by Dr. Thomas to LÖw,1175 in Vienna, which were discharged from the nose of a woman, aged 71, suffering from ozÆna, were recognized by the well-known dipterologist Braun as belonging to S. wohlfahrti. Among the cases reported by Joseph, one only affected the nose; it was that of a peasant girl, aged 11, who had suffered from ozÆna; she had travelled on the open road and had there gone to sleep. Severe symptoms set in and death followed under delirium. In making the post-mortem it was found that the interior of the nose was extensively destroyed by larvÆ of S. wohlfahrti. Powell found Sarcophaga larvÆ in two persons who had slept in the open air; the larvÆ were killed by injections of chloroform and sublimate. Destruction of the eyes by S. wohlfahrti has only been observed in a few cases; it is reported by Cloquet1176 that, in the case of a ragman who had lain some time in the fields, both eyes were pierced by larvÆ. On the outer skin the larvÆ of S. wohlfahrti have been found more than once in inflammatory or festering areas. Freund1177 demonstrated that from a five year old child, which had suffered for some time from an impetiginous eczema of the skin of the head, from two suppurating abscess cavities which extended to the periosteum, which was already affected, twenty-one living larvÆ were taken; rapid healing took place under antiseptic bandaging.

The small treatise by Balzer and Schimpff1178 contains two new observations on myiasis externa; in the one case an ulcer on a man’s foot was full of larvÆ, in the other case the head of a woman showed numerous larvÆ without the skin of the head being destroyed. Brandt’s1179 observation is interesting, for he found such larvÆ in the gums of a sick person.

The impression which one obtains of the active movement of larvÆ on wounds is a strange and at the same time uncanny one. One finds that the larvÆ to obtain protection against the drying of the surface of the abscess almost incessantly burrow with their heads, first contracting and then expanding the body, which rises and falls, and keeping the tail upwards. Owing to these movements producing irritation, increase of inflammation may ultimately arise, causing erysipelas and cellulitis.

The treatment of myiasis nasalis caused by Sarcophaga is the same as in myiasis caused by Lucilia, and in the other places where found it is merely a question of the removal of the larvÆ and the subsequent proper treatment of the surface of the abscess. In Northern Nigeria Lelean1180 found Auchmeromyia depressa to be the cause of myiasis externa.1181

The occurrence of Oestrid larvÆ in a human being is very rare, at least up till now myiasis oestrosa has been very seldom observed in man in Europe. Whilst the hosts of the MuscidÆ comprise a considerable number of warm-blooded animals, on which the larvÆ develop, each species of the OestridÆ appears, on the other hand, to have a definite host or some definite hosts of the class Mammalia. No species of Oestrid is peculiar to man. Although in America, as well as in Europe, Oestrus hominis was spoken of up to the middle of the last century, no such species exists.

But in both hemispheres, in America much more often than in Europe, Oestrid larvÆ have been found in man. In Florida, Mexico, New Granada, Argentina, Brazil, Costa Rica and other districts, and especially where large herds of cattle are kept, myiasis oestrosa has been observed in shepherds, huntsmen and amongst the rural population. The larvÆ of Hypoderma bovis, according to the observations of Goudot,1182 occur as a parasite in man. Poilroux1183 found larvÆ of cavicolous OestridÆ in the nose of a man, aged 55. Amongst the species of warble flies, whose larvÆ are parasites in domestic animals and game in Europe, reliable observers have found larvÆ of two kinds, Hypoderma bovis and Hypoderma diana, also in man.1184

The larvÆ of H. bovis have very seldom been observed in the nose. The case quoted by Kirschmann,1185 which was that of a peasant woman, aged 50, who was suffering from ozÆna, and in which violent attacks of sneezing, epistaxis, pain in the forehead, and swelling of the face were observed, is, according to LÖw1186 and Joseph,1187 not an Oestrid; Muscid larvÆ were evidently the cause. By the injection of diluted iron chloride solution seventy-nine larvÆ were removed from the nose. In the case reported by Razoux1188 the species of larva is not definitely known—at least, v. Frantzius1189 did not consider them Oestrid larvÆ. Joseph does not definitely say that Oestrid larvÆ were the cause of a case which he quotes. He was sent a number of uninjured larvÆ of Oestrus ovis ready to pupate, which were said to have been expelled, during violent sneezing, from the nose of a peasant woman who had suffered for six months from continuous frontal headache and chronic nasal catarrh.

The Oestrides prefer to use the surfaces of wounds on the skin of man to lay their eggs, which develop into larvÆ; but they often use their ovipositors1190 to make a fresh wound. In this case there arise in the skin, and particularly in the subcutaneous connective tissue of the neck, in the region of the shoulder, as well as in other parts of the body painful, furuncle-like inflammations which are known under the name of gad-fly boils. These boils may become the size of pigeons’ eggs; if several are together, they appear to form a connected tumour. Each tumour is elastic and somewhat movable, and has an orifice through which the larva breathes and discharges its excreta. At times these turn to festers and gangrenous disintegrations, which may even cause the loss of a limb. Wilms1191 had the opportunity a few years ago of observing a case of myiasis dermatosa oestrosa in Leipzig. The fistula which led to the larva was slit open and the larva extracted. As a notable characteristic of myiasis oestrosa Joseph states that the larvÆ grow very slowly. The flight time of the OestridÆ is the hot summer months.

Adams1192 observed on the Isthmus of Panama a number of cases of a skin disease which is caused by the larvÆ of Dermatobia noxialis (Gusano-peludo-Muche). The larvÆ penetrate not only the skin but also the mucous membrane of the pharynx and larynx, and from there proceed through the tissue to the subcutaneous cellular tissue. The infection seems to result from bathing.

The study of “thimni,” a human myiasis caused by Oestrus ovis, by Ed. and Et. Sergent,1193 deals more with the zoology and with the geographical distribution of this insect in North Africa than with the clinical appearances of myiasis. [This paper deals with matters of great interest, with important facts.—F.V.T.]

The treatment consists in the removal of the larvÆ (from the nose); in Brazil it is the custom to drop tobacco juice into the boil in order to kill the larvÆ (Strauch1194).

One is only justified in speaking of myiasis intestinalis when there is no doubt that living fly maggots or flies themselves can be proved to have been found in the fresh contents of the stomach or intestine (Schlesinger and Weichselbaum1195). In the discussion of myiasis intestinalis we give the evidence of Schlesinger and Weichselbaum, as well as that of Wirsing,1196 to which must be added a number of other investigations.

In a great number of acute cases apparently only the stomach was affected, there being no signs in the intestine. In these cases sudden illness is noticed, colic, sometimes unbearable pains in the region of the stomach, pyrosis, vomiting or continuous intense inclination to vomit, occasionally even with the mixture of blood. Frequently a general feeling of malaise, twinges of pain in the muscles, and attacks of giddiness were notified, very rarely fever. Generally all the symptoms disappeared in a short time when the larvÆ had been removed by an act of vomiting or by washing out the stomach.

It is well to note that in the history of many cases the pains preceding the expulsion of the larvÆ are stated to be extremely violent.

Acute myiasis of the intestinal canal frequently runs a course without special symptoms and is only an accidental condition; one has, however, in such cases to guard against errors. The fÆces may be deposited in vessels or places where fly larvÆ are in great numbers, or a subsequent infection of the fÆces with the eggs or larvÆ of flies may have taken place. Only when the inspection of the excrement immediately following defÆcation proves the presence of living larvÆ, and when there were certainly no fly larvÆ in the vessel previously, can one speak of the passing of fly larvÆ from the intestine. More frequent than the cases showing no special symptoms are those with pronounced disturbances in the intestinal passage, obstruction or diarrhoea (also constipation and diarrhoea alternately), violent and sometimes agonizing abdominal pains (Pottiez1197), which preceded the evacuation of the larvÆ and subsided after their removal. General symptoms, like weakness, languor, transitory vague pains, loss of appetite, sickness, rarely fever, giddiness, attacks of faintness, epileptic attacks (Krause1198) are observed. In a few cases blood and pus have been noticed in the evacuation of the bowels.

In the cases of chronic myiasis of the intestine the aspect of the disease is dominated by the complex symptom of colitis mucosa.

The following features are noticeable, namely, the intermittent passing of blood, the influence over the expulsion of the larvÆ of mechanical procedure (massaging of the abdomen), the duration of the process for several years, the sometimes enormous number of insects contained in the dejecta. Another clinically important factor is the passing of the larvÆ in batches. While for some time no larvÆ may appear in the stools, they may suddenly be ejected in great numbers, either because the conditions of feeding are not suitable, or because medicaments remove them from the intestine. The hÆmorrhage is ascribed by Schlesinger and Weichselbaum directly to lesions of the mucous membrane caused by the larvÆ; in the case reported by these writers there were found shreds of tissue as well as pus in the stool. The pains occurring spontaneously in the abdomen are at times influenced by position and attitude of the body, often they were more violent after rest and after evacuation of the bowels; often they were continuous, but in that case less intense; pressure on the abdomen is generally little felt. The condition of the blood was in two cases (Pasquale1199 and Schlesinger and Weichselbaum) a marked chlorotic one. The state of nutrition seems almost always to suffer with prolongation of the disease, but in Peiper’s1200 cases this was not so. The condition of the appetite was in some instances good, in others very bad. A frequent symptom is headache of a migraine-like character and neuralgic pains in different parts.

Schlesinger and Weichselbaum’s case shows that there are forms of myiasis intestinalis which, after prolonged sickness, lead to death, and that in consequence of the formation of intestinal abscesses stricture of the intestine may arise from the subsequent formation of a scar.

The question of the mode of infection is interesting; in this mouth, nose and anus must be considered. The most frequent way is certainly by means of food on which flies have laid their eggs, or which is permeated with young maggots. This may be raw (especially grated) meat, cheese, fruit, salad, milk, cabbage, cold farinaceous foods, raspberries. When the stomach is affected, when the gastric juice has lost acidity and power of digestion, the larvÆ will be able to stay and develop more easily. According to Csokor,1201 if the eggs get into the gastro-intestinal canal of man with the food, the delicate stages of the young larvÆ would certainly not survive the action of the gastric juice. Salzmann1202 assumed that the invasion occasionally occurred through the rectum, the larvÆ creeping into the anus while the person is asleep. Wirsing accepts this method of infection for two of his cases, where it was a question of the infection of an infant. Salzmann1202 reports a case where the maggots of Anthomyia1203 scalaris were passed in great numbers from the urethra of an old man. The patient had been catheterized on account of urethral stricture and was probably infected with eggs or larvÆ at the same time.

The diagnosis of the affection is easy and sure, if living larvÆ are found in the contents of the stomach or in the stools, and if contamination is out of the question.

The number of different species of flies whose larvÆ are found in myiasis intestinalis is considerable. The larvÆ of species of Anthomyia (A. canicularis,1204 A. scalaris, etc.), of Sarcophaga carnaria and S. magnifica and of Musca vomitoria1205 are especially observed.

The prognosis is certainly generally favourable, but must be made with some reserve in chronic cases, in view of the observations of Schlesinger and Weichselbaum (intestinal stenosis).

The treatment must aim at removing the larvÆ as soon as possible from the digestive canal.

In cases of myiasis of the stomach, a thorough washing out of the stomach (Joseph,1206 Staniek1207) is to be preferred to emetics used with success in individual instances; perhaps it would be advisable to add menthol or thymol to the mixture.

In myiasis of the intestine internal remedies and local treatment of the intestine must be considered.

So far santonin seems to have proved to be the best remedy. In some cases extract. filicis maris, calomel, semina cucurbitÆ, naphthalene 0·1 to 0·5 (Peiper1208), infus. of Persian insect powder (5 in 200), mineral waters, Carlsbad water, seem to have had good results.

For irrigation of the rectum, weak solutions of argentum nitricum, tannin, thymol, gelatine, ol. ricini, naphthalene may be used. Wirsing administered an aperient (Rurella compound liquorice powder) and a soap enema after the passing of the first larvÆ.

The principal thing is the prophylaxis, which must include the careful protection of articles of food, on which flies may lay their eggs (protection by glass dishes, tulle or fine wire nets). Fruit should not be eaten before being washed or rubbed with a cloth.

Gastricolous OestridÆ (Creeping Disease).

Syn.: Creeping eruption; Larva migrans; Hautmaulwurf; Dermatomyiasis linearis migrans oestrosa; Hyponomoderma; Dermatitis linearis migrans; Linea migrans; Epidermiditis linearis migrans Wolossatik; Kriechkrankheit; Hautkratzschorf; Myiase hypodermique.

Under the name “creeping disease,” R.J. Lee1209 has recorded a peculiar affection of the skin in a three year old girl, which appeared first in the form of pale red, thread-like irregular protuberances, which seemed partly to become entwined on the right malleolus and had spread without causing special disturbances to the abdomen. Dickinson, Fox and Duckworth1210 reported, in connection with this, that they observed a growth of this red line of about 1in. per diem. Since then a number of similar cases have been reported which, without doubt, were cases of larvÆ creeping under the skin. Crocker1211 saw such a case in a two year old girl, the progress of the red line varying in one night between 4 and 7 1/2in. In Europe the first case was observed in Vienna, by v. Neumann and Rille,1212 also in a two year old girl.

v. Samson-Himmelstjerna,1213 Sokoloff,1214 Rawnitzky1215 found larvÆ at the end of the tract, which had been recorded as larvÆ of Gastrophilus by Cholodowsky.1216 According to Blanchard (Arch. f. Par., 1901) the larvÆ were those of Hypoderma bovis.

How these larvÆ get into the skin has not yet been definitely ascertained; v. Samson is of the opinion that they usually obtain access to man as larvÆ, Stelwagon1217 believes that the infection generally occurs in a seaside watering place; a patient of Ehrmann’s1218 fell ill when he returned from the manoeuvres, where he had lain for some time on the ground. Here and there it is reported that the eruption was preceded for a longer or shorter time by lesions of the skin (incised wounds, furuncles, slight excoriations, v. Harlingen1219).

Twice it has been suggested that perhaps the parasites might come from vineyard snails (Crocker, Lenglet and Delaunay1220), and it is pointed out by v. Samson that in Russia the infection of peasants who work in the fields was specially frequent. It is noticeable how frequently the affection begins on uncovered parts of the body (face, hands, arms); but that fact, on the whole, is not in conflict with the statement (Kengsep1221) that the disease makes its first appearance over the nates, because children often sit on the ground and play with that part of their body uncovered. A case observed by us was that of an elderly lady who did not do this and was properly clothed, yet showed the typical lines of creeping disease on the nates, and asserted again and again that she had the feeling as if a worm were creeping under her skin.

The disease occurs in children as well as adults, so that age, sex and calling offer no determining point etiologically.

The clinical symptoms of the disease consist in the sudden appearance of itching and burning; if the cause is looked for one perceives a red line, raised but little above the surface of the skin, with irregular curves, never branched, but often entwined, broadening more or less rapidly at one end (1 to 15cm. in twenty-four hours). The larva can be seen sometimes with a lens under pressure of the skin as a dark spot; formations of pus, such as other larvÆ produce, are not noticed; now and again there is a formation of little vesicles (Hamburger,1222 v. Harlingen,1223 Bruno,1224 Ehrmann,1225 Brodier and Fouquet,1226 Rawnitzky1227). It may happen that the parasite burrows through a small region of the skin with many close curves for some time; on the other hand, observations exist where it covered large tracts in a short time. The itching and smarting cease in the place left by the larva, so that the patients even in the shortest tract can point out at which end the larva is, even if they have not watched the lengthening of the tract. Very rarely the larva invades the mucous membrane of the mouth, the nose, and the conjunctiva, proceeding from thence to the external cutaneous area.

The localization of the affection is very varied; the primary seat has been observed on the glutei muscles (Lee, Kengsep, Morris,1228 Rille, Seifert) and their surroundings (Stelwagon, Hamburger, Bruno), on the lower extremities (Stelwagon, Lenglet and Delaunay, Hutchins, Moorhead, Lee, Crocker, Schmid,1229 v. Harlingen), on the upper extremities (Samson, Meade and Freeman, Hutchins, Sokoloff, v. Harlingen, Brodier and Fouquet, Shelmire,1230 Stelwagon), on the face (Sokoloff, Moorhead, Kumberg,1231 Rawnitzky, Crocker, Boas1232), on the neck (Sokoloff), and on the body (Ehrmann, Brodier and Fouquet, Kaposi,1233 Topsent1234).

The duration of the affection varies very much; it varies between a few hours and some years1235; several times a spontaneous recovery has been reported.

The diagnosis of the disease is not at all difficult owing to its peculiar appearance.

The treatment can only consist in the removal or killing of the larvÆ, since one cannot rely on spontaneous recovery, even if it has occurred in some cases. If one should succeed in locating the larva as a black spot at the end of the tract, its removal by means of a needle is the simplest method (Quortrup and Boas1236). In some instances a cure has been successfully accomplished by excision of the active end of the tract (v. Neumann and Rille, Schmid). In opposition to this method, which not all patients will allow, the method practised by Arab women (Rille and Riecke1237) of killing the worm with red hot needles is quite rational. Shelmire1238 used the electrolytic needle for the destruction of the maggots, Stelwagon1239 made use of cataphoresis, by means of which he applied a sublimate solution, afterwards cauterizing with a drop of nitric acid, as excision was refused. Crocker1240 and v. Harlingen1241 injected small quantities of carbolic acid; Moorhead1242 by a single freezing of the skin with ethyl chloride, attained a definite cessation of the attack at the active end. Hutchins1243 in one case made use of hypodermic injection of a few drops of solution of cocaine and afterwards of 1 to 2 drops of chloroform; in a second case of repeated applications of tincture of iodide, as Lenglet and Delaunay1244 did. v. Harlingen1245 allayed the affection in his first case by rubbing in sapo viridis and tar, in Kensep’s1246 case the cure seems to have been accomplished by an ointment containing resorcin, in Meade and Freeman’s1247 case by a 20 per cent. ichthyol paste. In our case we made exclusive use of Lassar’s paste; within four weeks a cure resulted, probably spontaneously, since one cannot ascribe any essential effect to this paste.