Nematodes

Strongyloides stercoralis.

The pathological significance of this intestinal parasite is not yet fully demonstrated. In Seifert’s observation, on what Leichtenstern called the celebrated Würzburg case, the patient had suffered many times from attacks of blood-stained diarrhœa with tenesmus, as in Zinn’s case of a three year old boy who had bloody purulent diarrhœa. Schlüter 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, Valdes, and Trappe), so that even if in isolated cases (Fülleborn) symptoms are absent, some significance cannot be denied these parasites as a matter of course (Bruns, Leichtenstern). According to Kurlow, 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. Goldmann 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, Valdes, Soussino, Goldmann), has often caused diminution of the number of larvæ, but also often remains resultless. Teissier 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. Davaine believes he attained decrease and final disappearance of the larvæ by protracted milk-cure. Santonin, tannalbin and other preparations seem ineffectual. Tannin enemata (Mildner), high injections with starch enemata (Schlüter), 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 (Trappe).

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-Desportes (fifty worms) and by Harington (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. Emily makes injections of a 1 in 1,000 solution of sublimate either in the neighbourhood of the worm or directly into its body. Mense 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 (Frangenheim) 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 (Finucane).

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 (Bancroft).

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 (Ziemann 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 (Ziemann). 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, 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. Ziemann 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 Cleri (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 Pollack (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. Martens 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, Eichhorst, Askanazy), 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. (Moosbrugger and Kahane 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, Schulze, Kahane, Vix, Girard and Blanchard all found changes in the mucous membrane of the gut, showing that the parasites had been in the gut for a considerable time. Kahane 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, Kahane, Girard, Poledne, and Rippe. 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. Becker obviously used too much benzine (1 dessert-spoonful to 1 litre of water), for severe irritation was set up, whilst Peiper 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’s 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, Langenbeck, Babes). 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 Schleip (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. Stäubli 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.

Moscato 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 Stuertz 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 Bruns). 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. Ziemssen and Huppertz, 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 (Baravalle), the eosinophile cells increase considerably (Boycott, Lohr), yet in regard to diagnosis eosinophilia cannot be regarded as of equal value to a microscopical examination of the fæces (Bruns, Liefmann, and Meckel). 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 (Inouye), or from putting food into the mouth with dirty hands. Looss 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, itching papules in their own skin, and Dieminger 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) (Dubreuilh); the penetration of the larvæ through the skin also explains the frequent appearance of boils and itching purulent eczema in miners in infected pits (Goldmann).

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) (Goldmann).

(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, Goldmann, and Dieminger recommend washing out with freshly prepared lime water with the addition of caustic soda; Calmette and Manouriez spraying with salt water. Theoretically spraying with hot water or steam should be done every now and again for the destruction of the larvæ (Looss). 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 Manson it is advisable in the tropics to cover the naked hands and feet with green Barbados tar, and the tarred parts thickly with flour; Fabre 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 Bozzolo 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, Grünberger, Smith) or cascara sagrada (Mann), 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. (Prowe), 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. Sandwith and Thornhill, as well as Leichtenstern, even record cases of death after the use of thymol; 4 grm. thymol caused severe symptoms of poisoning in Grünberger’s 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 Goldmann 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 (Goldmann and Liermberger).

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, Bauer); Leonardi 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 (Mann), whilst the reverse is frequently observed (Grünberger). Nagel 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. Zinn prefers extract. filicis maris (freshly prepared) to all other drugs. Warburg 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 (Nagel). Opinions are divided as to the combination of thymol and extractum filicis maris (Hynek, Stockman, Boycott and Haldane, Adams). As regards other remedies, eucalyptus oil is well spoken of by Philips and Hermann: 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). Neumann 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. Bentley 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, Liermberger) 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, Clason 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’s 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. Sick 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 Borger collected fifty-nine cases relating to the invasion by Ascaridæ of the bile-ducts and passages, and Dauernheim’s Dissertation treats of this question as well. A further case of Ascaris in the ductus choledochus (choledochotomy) is recorded by Neugebauer. In the case of Schupper (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, 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. Epstein confirms the correctness of the explanation of the mark of strangulation in an Ascaris in Mertens’ 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 Vierordt 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 (Quincke), 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, Saltykow). Leer 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’s 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 Peiper) without giving rise to special symptoms. For example, Troja found in the frontal sinus of a cadaver a large coiled-up Ascaris which occupied the whole cavity. Wrisberg made the same observation in the cadaver of a boy. Deschamps and Fortessin 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, in which an Ascaris was removed from the nose of a girl, aged 7; also the case recorded by Benievini, 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, Lanzoni, Langelott, Tulpe, Reisel, Fehr, Bruckmann, Bahr, Slabber, Lange, and Chiari. A rarer case is that recorded by Haffner, 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, Jurasz 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 Reynolds and Wagenhäuser; in the case recorded by Turnbull (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. Oesterlein records a fatal attack of choking from Ascaridæ in the trachea. In a case recorded by Smyly 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. Fürst collected twenty-five observations of invasion of the larynx and trachea by Ascaris. Mosler reports the case of a patient with aphonia and dyspnœa from whose larynx an Ascaris was removed. Donati reports a case of four Ascarides in the larynx, and Cerchez of asphyxia from Ascarides in the larynx or trachea. Wagner 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 Rabot; 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’s 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. Schlüter 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’s 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. Metschnikoff 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). Guermonprez 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. Küchenmeister has already recommended combination of santonin with ol. ricini. Lewin, however, states that ol. morrhuæ, ol. olivarum, ol. cocos and ol. cinæ can also be taken. In prescribing santonin in oily solution Henoch also prefers the combination with ol. ricini. According to Lewin’s direction the prescription would run as follows:—

℞ Santonin

0·

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:—

℞ Santonin

0·

2 grm.

Ol. ricini

20·

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:—

℞ Santonini

0·

01 to 0·02 to 0·03 grm.

Calomelan

0·

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 Schidlowsky 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, Hausmann), also β-naphthol up to 0·45 grm. three times daily (Du Bois), and—

℞ Benzo-naphthol

2·0

grm.

Semin cinæ

1·0

grm.

Sacch. albi.

0·5

grm.

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

(Ferran), filmaron oil 1·0 to 2·0 to 3·0 grm. in gelatine capsules, according to age (Bodenstein). Brüning, 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. Thelen 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 (Ungar). 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 (Trendelenburg). The conditions recorded by von Wagener and Ruffer 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), and these do not abate till after the removal of the oxyuriasis. Some authors speak of an oxyuriasis cutanea (Majochi), in the more limited sense of a dermatitis intertriginoides. So far five such cases have been recorded, one each by Szerlecky, Michelson, Majochi, Barbagallo and Vignolo-Lutati. 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 (Zarniko) (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. Chiari 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 Hartmann; 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. Rheins 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. Proskauer 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’s 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 (Heller). With regard to the second point, one has to observe strict cleanliness in general (Barbagallo 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, 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). Dornblüth employs the same medicament in a form only slightly modified from Ungar’s method, Barbagallo 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, Still), 1/2 per cent. salicylic acid solution or liq. alum. acet. (one tablespoonful to a litre of water, Dornblüth), or gujanosol (2 to 3 to 4 to 5 per cent. solution, Rahn). The employment of benzine for such high injections is not advisable according to the experience of Senger, 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 (Seifert). 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, 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.