SUPPLEMENT: CLINICAL AND THERAPEUTICAL NOTES. (continued 2)

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 1 cm. long and 2 mm. 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 1·0 grm., pulpa tamar. depur. 2 grm., syrup of sugar 50·0 grm., 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 3·0 grm. 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 2·0 grm. extr. fil. maris, with mint syrup or raspberry syrup 30·0 grm., in the morning twice an hour by the mouth, or 1·0 grm. 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 diarrhœa, 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. 0·5 grm. three times a day for two days, then 1·0 grm. 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 diarrhœa, 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 Pharmacopœia 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 15 grm. are to be taken in gelatine capsules within half an hour. We consider it unjustifiable to give greater doses than 15 grm. to adults, as many cases are known in which to some extent severe toxic symptoms have followed, such as headache, sensation of giddiness, dyspnœa 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 œdema. 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 8·0 grm. 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 āā 0·2 grm. (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 0·3 grm., for children of from 8 to 12 years in doses up to 0·5 to 0·7 grm., and for adults up to 0·7 to 1·0 grm., 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 4 grm.). 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 diarrhœa, 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 0·4 grm., acid. tannic. 0·5 grm., sir. rub. jd. 30·0 grm., 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 20 grm. in compressed form or in sugar or honey in the form of electuaries (children 2·0 to 10·0 grm. 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 2·0 grm. 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 2·0 grm.) 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 3·0 grm. 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 3 grm. 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 diarrhœa with tenesmus, as in Zinn’s781 case of a three year old boy who had bloody purulent diarrhœa. Schlüter782 speaks of a hæmorrhagic enteritis produced by Strongyloides. In other cases besides diarrhœa (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 diarrhœa 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 0·2 grm. and tuber. jalapæ 0·5 grm. a day before the special treatment, which consists of gelatine capsules of 15·0 grm. 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 diarrhœa. 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 diarrhœa.

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 (0·12 grm. dose several times daily), ichthyol (in pills from 0·5 to 1·5 grm. per day), ol. terebinthinæ (0·5 to 1·5 gr. 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 diarrhœa 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 diarrhœa, 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 0·06 grm., rheum. 0·3 grm., tinct. ferri sesquichlor. 1·2 c.c., aq. dest. 90·0 grm., 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 diarrhœa, with colic, great muscular fatigue, œdema 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, œdema 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 œdema 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 (0·5 grm.), 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 250 c.c. a day) is recommended by some, also glycerine (150 grm. 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 œdematous 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 diarrhœa 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, œdema 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 15 grm., in single doses of 2 grm. 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; 4 grm. 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 3 grm. per diem (children up to 1·0 grm.) on four consecutive days, and at the end of the treatment a purge (Pool,870 Bauer871); Leonardi872 speaks well of thymol essence (4·0 c.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 10 grm., chloroform 10 to 15 drops, syr. sennæ 16 grm.; 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 0·7 grm., thymol 5·0 grm., chloroform 1·5 grm., ol. ricini 20·0 grm. 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 2·0 grm., chloroform 3·0 grm., ol. ricini 30·0 grm., 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 0·035 grm. Podophyllin appears to produce quite a peculiar condition of the intestinal mucosa which is very prejudicial to the Ancylostoma adhering to it. Bentley886 regards β-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 1·0 grm. (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, œsophagus, 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, fœtid 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 dyspnœa 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 0·5 grm. to 2 grm. (children and adults).

Santonin is prescribed either in single doses from 0·03 to 0·05 to 0·1 grm. 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:—

℞ Santonin0·2 grm.

Ol. ricini.20·0 grm.

Ol. cinæ æth.gtt. iv.

M., d.s.

S., one tablespoonful to be taken two to three times.

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

℞ Santonin0·2 grm.

Ol. ricini20·0 grm.

Ol. cinæ æth.gtt. iv.

Sacch. albi.q.s.

Pasta moliis.

S., to be used for two days.

If necessary the first-mentioned mixture might be given in gelatine capsules. Small children should be given 0·025 grm. 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:—

℞ Santonini0·01 to 0·02 to 0·03 grm.

Calomelan0·025 grm.

Sacch. albi.0·5 grm.

M.f.p. D. tal. dos. x.

S., one powder about six, seven, and eight o’clock on three con­sec­utive days.

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 0·06 grm. 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 2·0 grm. per diem (Calderone,945 Hausmann946), also β-naphthol up to 0·45 grm. three times daily (Du Bois947), and—

℞ Benzo-naphthol2·0 grm.

Semin cinæ1·0 grm.

Sacch. albi.0·5 grm.

M., f.p. Divide in part. æq. xxii. S., three to five powders daily.

(Ferran948), filmaron oil 1·0 to 2·0 to 3·0 grm. 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. 10·0 grm., vitelli ovi unius, ol. amygd., gi. arab. pulver. āā 10·0 grm., aq. destill. 200 grm.; f. emulsio) up to 0·25 to 0·5 grm. 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 6 in. 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 œsophagus, 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 0·1 grm. (children of 1 year old), 0·1 to 0·2 grm. (children of 2 to 3 years old) and 0·2 to 0·4 grm. (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 0·1 grm. 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.

An essay has been published by Hippius and Lewinson (Deutsch. med. Wochenschr., 1907, xliii.) in which the relationship of Oxyuridæ to appendicitis is considered and the treatment of oxyuriasis is discussed. The instructive case recorded appears to show that germs through Oxyuridæ gain access to the tissue of the appendix, and, indeed, are carried in by them. In view of this more recent communication as to the part which intestinal parasites play in the etiology of appendicitis, it seemed to me [O. S.] to be worth while to interrogate my surgical colleagues as to this point. About 2,000 appendicectomies have been jointly performed by Drs. Burkhardt, Enderlen, Pretzfelder, Riedinger, Rosenberger and Siber, and in not one of these cases could entozoa be found to be a possible cause of the appendicitis. Such figures without doubt speak in favour of the fact that even if in individual cases entozoa might come into reckoning as a possible cause, such an etiological factor must be classed among the greatest of rarities. My colleague, Dr. Ries, who practised for ten years in Mexico, informed me that there practically speaking every Indian without exception harboured parasites of the most varied kind, and that in spite of the very extensive professional standing he enjoyed among these people he never had under observation among them a single case of appendicitis. As far as the observation of the authors in question as to the treatment of oxyuriasis is concerned, it must be energetically directed to the employment of local measures for the intestine; they maintain that the use of enemata would be irrational, and that it is astonishing that this method has been able to maintain its standing down to the present day.