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 (Krüger[700]), emaciation (Zschokke), or even nervous symptoms of central origin in the form of convulsions (Brandt[701]) 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 Huber[702] 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 (Rosenberg[703]). 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. [693] Bollinger, _Deutsch. Arch. f. klin. Med._, 1905, lxxxiv. [694] Köhl, _Münch. med. Wochenschr._, 1904. [695] Lindblad, _Hygiea_, xlv. [696] Sonnenschein, _Münch. med. Wochenschr._, 1903. [697] Asam, _Münch. med. Wochenschr._, 1903. [698] Zschokke, _Centralbl. f. Bakt._, 1905. [699] Pollak, _Wien. klin. Wochenschr._, 1907. [700] Krüger, _St. Petersb. med. Wochenschr._, 1887. [701] Brandt, _Centralbl. f. Bakt._, 1889. [702] Huber, suppl. to Asam, _Münch. med. Wochenschr._, 1903. [703] Rosenberg, _Ges. f. innere Med._, February 16, 1904. 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 Haendel[705]). 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 (Lutz[706]). Possibly, too, _Hymenolepis nana_ infects the urinary organs, producing true chyluria (Predtetschensky[707]). 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 Grassi[708] 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. [704] Nicolo, _Gaz. d. Osp._, 1904. [705] Stoerk, E., and Haendel, _Wien. klin. Wochenschr._, 1907, xxix. [706] Lutz, _Centralbl. f. Bakt._, 1894. [707] Predtetschensky, _Zeitschr. f. klin. Med._, xl. [708] Grassi, _Centralbl. f. Bakt._, 1887. _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 Bordier[709] in studying a case of chyluria found this species in the kidneys of a person in Madagascar. [709] Bordier, quoted by Predtetschensky, _loc. cit._, p. 95. 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 Steinhaus[710] 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. [710] Steinhaus, _Deutsch. med. Wochenschr._, 1903. 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 Posselt[711] 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 (Wolff[712]). Frangenheim[713] recommends early extirpation (this, however, only in the case of solitary cysts). Pelagutti[714] 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 Gaetano[716] (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 (Huber[717]). 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 (Kaldrovils[718]). 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. [711] Posselt, _Wien. klin. Wochenschr._, 1899. [712] Wolff, “Lesser’s Encyclop. d. Haut- u. Geschlechtskrankh.,” 1900. [713] Frangenheim, _Volkm. klin. Vortr._, No. 424. [714] Pelagutti, _Giorn. ital. delle mal. vener._, 1900. [715] Glas, _Wien. klin. Wochenschr._, 1905. [716] Gaetano, _Giorn. int. delle Sci. med._, 1904. [717] Huber, “Bibliographie der klin. Helminthologie,” 1891, pt. 2. [718] Kaldrovils, _Wien. med. Wochenschr._, 1902. 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. (Orth[719]). 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 (Sipari[720]). 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 (Henneberg[721]). 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-Thorn[722]), 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 Jacobson[723] 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. Bergmann[724] 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] Versé[726]). Stern[727] 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 (Jolasse[728]). 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 (Hartmann[729]). 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. [719] Orth, _Berl. med. Ges._, June 29, 1904. [720] Sipari, “Angelo Trani Neapel,” 1900. [721] Henneberg, _Berl. klin. Wochenschr._, 1906, xxxii. [722] Hagen-Thorn, abstract by Posselt. [723] Jacobson, _Berl. klin. Wochenschr._, 1906. [724] v. Bergmann, quoted by Frangenheim, _loc. cit._, p. 470. [725] Simmonds, _Münch. med. Wochenschr._, 1907, xxvii. [726] Versé, _Münch. med. Wochenschr._, 1907, xi. [727] Stern, _Zeitschr. f. klin. Med._, lxi. [728] Jolasse, _Münch. med. Wochenschr._, 1896. [729] Hartmann, _Wien. klin. Wochenschr._, 1902. 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 Meyer[730] symptoms which resembled paralysis agitans were noteworthy, and defects in speech in the case recorded by Durst[731] (_C. racemosus_ in the region of the left Sylvian fossa). According to Markwald[732] _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, Remmert[733] recommends that the skin of the whole body should be palpated. [730] Meyer, _Deutsch. med. Wochenschr._, 1906. [731] Durst, _Lieven. viestnik_, 1902. [732] Markwald, _Münch. med. Wochenschr._, 1895. [733] Remmert, “Dissert. Berlin,” 1893. 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_ (Kleefeld[734]). 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. [734] Kleefeld, _see_ Seifert _loc. cit._ Tapeworms are found not uncommonly with other intestinal parasites, such as Ascaris, Oxyuris, Trichocephalus or Ancylostoma. Prunac[735] described a case in which a woman passed a Tænia through the anus while she vomited a _Fasciola hepatica_. [735] Prunac, _see_ Eichhorst, “Handb. d. spez. Path. u. Therap.,” ii, p. 281. 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-Valerio[736] 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. [736] Galli-Valerio, _Therap. Monatsh._, 1900. 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 Fischer[737] 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. [737] Fischer, Stockholm, Nordin and Josephson, 1904. 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 Grawitz[738] 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. [738] Grawitz, _Münch. med. Wochenschr._, 1899. [739] Boas, _Deutsch. med. Wochenschr._, 1889. 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’s[740] Dissertation. Since that time further instances of such intoxications have been made known. Nagel[741] observed them only in severe cases. O. Meyer[742] lays special stress on the bad prognosis of the disturbances of vision evoked by poisoning with extract. filicis maris. Studt[742] has seen two cases of optic neuritis, one with circumscribed, the other with diffuse retinal œdema. Uhthoff[743] has only seen one case; in that reported by Noiszewski[744] the toxic retinitis was cured; in Viereck’s[745] case bilateral concentric limitation of the field of vision followed three days after taking 8·0 grm. extract. filicis maris. Stuelp[746] 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. Huber[747] 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. Marx[748] 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. Sonnenschein[749] also advises against the simultaneous exhibition of extractum filicis maris with oleum ricini, as is the case with Helfenberg’s capsules, and Boas[750] is likewise anxious that ol. ricini should be avoided. Lenhartz[751] 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. (Apolant[752]) half an hour before the drug is taken. Fischer[753] considers that lying still in the horizontal position is the best remedy. Boas[754] 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 Fowler[755] 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. [740] Marx, “Diss. Würzburg,” 1903. [741] Nagel, _Deutsch. med. Wochenschr._, 1903. [742] Meyer, O., _Berl. klin. Wochenschr._, 1905. [743] Studt, _ibid._, 1905. [744] Uhthoff, _ibid._, 1905. [745] Noiszewski, “Postepokuhst,” 1906. [746] Viereck, _Arch. f. Schiffs- u. Tropen-Hyg._, 1906. [747] Stuelp, _Arch. f. Augenheilk._, 1906, li. [748] Huber, M_ünch. med. Wochenschr._, 1903. [749] Marx, _loc. cit._ [750] Sonnenschein, _Münch. med. Wochenschr._, 1903. [751] Boas, _loc. cit._ [752] Lenhartz, _loc. cit._ [753] Apolant, _Deutsch. med. Wochenschr._, 1905, xliv. [754] Fischer, _loc. cit._ [755] Boas, _loc. cit._ [756] Fowler, _Brit. Med. Journ._, 1906. Under Jaquet’s[757] 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. Bodenstein[758] 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. Brieger[759] 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. [757] Jaquet, _Therap. Monatsh._, 1904. [758] Bodenstein, _Wien. med. Presse_, 1906. [759] Brieger, “Therap. d. Gegenwart.,” 1905. The attempts made by Goldmann[760] 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 Liermberger[761] are sufficiently encouraging to be put to further test. [760] Goldmann, _Wien. klin. Wochenschr._, 1905. [761] Liermberger, _Berl. klin. Wochenschr._, 1905. Fischer[762] 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.). Laurén[763] had previously recorded similar results, and recently Friedjung,[764] using extr. aspid. spinulos. [762] Fischer, _loc. cit._ [763] Laurén, _Therap. Monatsh._, 1899. [764] Friedjung, _Ges. f. innere Med._, Wien, March 8, 1906. 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 (Drivon[765]). Sometimes, judging by the experience of Sobotta[766] 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] Pick[769]), Jungklauss’s preparation is nothing else than a pumpkin extract; its action is favourable; it is, however, too expensive (Ritter[770]). 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 Langgard[771]). 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 Leichtenstern[772] and White[773] chloroform, even in toxic doses, cannot do any harm to the tapeworm, nevertheless it has been recently recommended by Carratú[774]; chloroform 6·0, sirup. 60·0, one teaspoonful to be taken every hour (fasting). Salol is recommended by Galli-Valerio[775] 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. [765] Drivon, _Lyon méd._, 1902. [766] Sobotta, _loc. cit._ [767] Boas, _loc. cit._ [768] Storch, _see_ Lenhartz, _loc. cit._ [769] Pick, _Ges. f. innere Med._, Wien, March 8, 1906. [770] Ritter, _Prag. med._ Wochenschr., 1904, v. [771] Liebreich and Langgard, “Kompendium der Arzneiverordnung,” 1907. [772] Leichtenstern, “Therap. der Gegenwart.,” 1899. [773] White, _Scot. Med. and Surg. Journ._, 1900. [774] Carratú, _Giorn. med. del regio eserc._, 1903. [775] Galli-Valerio, _Therap. Monatsh._, 1900. [776] Pool, _Med. Woche_, 1901. 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) (Koch[778]). The coconut is absolutely ineffectual, also naphthalin, croton-chloral, ether, gallanol, strontium lactate, glycerine and bromide of potash. [777] Dörr, “Therap. der Gegenwart.,” 1901. [778] Koch, _Med. Klinik_, 1907. 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’s[779] observation, on what Leichtenstern[780] called the celebrated Würzburg case, the patient had suffered many times from attacks of blood-stained diarrhœa with tenesmus, as in Zinn’s[781] case of a three year old boy who had bloody purulent diarrhœa. Schlüter[782] 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 Trappe[785]), so that even if in isolated cases (Fülleborn[786]) symptoms are absent, some significance cannot be denied these parasites as a matter of course (Bruns,[787] Leichtenstern[788]). 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. [779] Seifert, “Sitzungsberichte der phys.-med. Ges. in Würzburg,” 1883. [780] Leichtenstern, _Arbeiten aus d. kaiserl. Gesundheitsamte_, 1905, xxii. [781] Zinn, _Berl. klin. Wochenschr._, 1900, xlix. [782] Schlüter, “Diss. Kiel,” 1905. [783] Silvestri, _see_ Schlüter _loc. cit._ [784] Valdes, _ibid._ [785] Trappe, _Deutsch. med. Wochenschr._, 1907. [786] Fülleborn, _Biol. Abt. d. ärztl.-Vereins in Hamburg_, October 14, 1902. [787] Bruns, _Münch. med. Wochenschr._, 1907, xix. [788] Leichtenstern, _Deutsch. med. Wochenschr._, 1898. [789] Kurlow, _Centralbl. f. Bakt._, 1902. 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[790] 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] Goldmann[794]), has often caused diminution of the number of larvæ, but also often remains resultless. Teissier[795] 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[796] believes he attained decrease and final disappearance of the larvæ by protracted milk-cure. Santonin, tannalbin and other preparations seem ineffectual. Tannin enemata (Mildner[797]), high injections with starch enemata (Schlüter[798]), 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[799]). [790] Goldmann, _Deutsch. Aerzte-Zeitg._, 1903. [791] Schlüter, “Diss. Kiel,” 1905. [792] Valdes, _loc. cit._ [793] Soussino, _see_ Schlüter _loc. cit._ [794] Goldmann, _loc. cit._ [795] Teissier, _Arch. d. Méd. exp._, 1895. [796] Davaine, _see_ Seifert, _Deutsch. med. Zeitg._, 1885. [797] Mildner, _Berl. med. Ges._, July 24, 1907. [798] Schlüter, _loc. cit._ [799] Trappe, _loc. cit._ *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[800] (fifty worms) and by Harington[801] (seventeen worms). [800] Poupée-Desportes, _see_ Looss, “Handb. d. Tropenkrankh.,” 1905, i. [801] Harington, _Brit. Med. Journ._, 1906. 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[802] makes injections of a 1 in 1,000 solution of sublimate either in the neighbourhood of the worm or directly into its body. Mense[803] 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[804]) favour the free laying open of the existing abscess and the consequent complete extraction of the worm. [802] Emily, _see_ Looss _loc. cit._ [803] Mense, _ibid._ [804] Frangenheim, _Volkmann’s Samml. klin. Vorträge_, 424. 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[805]). [805] Finucane, _Lancet_, 1907. 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[806]). [806] Bancroft, _Lancet_, 1885. 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[807] 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. [807] Ziemann, _Deutsch. med. Wochenschr._, 1905, xi. 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[808]). 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. Ziemann[810] 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[811] (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[812] (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[813] exhibited a Filaria extracted from the eyelid under local anæsthesia. [808] Ziemann, _Deutsch. med. Wochenschr._, 1905. [809] Pick, _ibid._ [810] Ziemann, _loc. cit._ [811] Wurtz and Cleri, _Arch. Méd. expér._, 1905, ii. [812] Pollack, _Berl. ophthal. Ges._, May 17, 1906. [813] Martens, _Berl. med. Ges._, July 24, 1907. *Trichuris trichiura.* Whilst many authors consider the whip-worm as a harmless parasite of the large intestine (Leichtenstern,[814] Eichhorst,[815] Askanazy[816]), 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[817] and Kahane[818] 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. [814] Leichtenstern, “Handb. d. Therap. v. Pentzoldt-Stintzing.” [815] Eichhorst, “Handb. d. Spez. Path. u. Therap.” [816] Askanazy, _Deutsch. Arch. f. klin. Med._, 1896. [817] Moosbrugger, _Med. Corresp.-Bl. f. Württemburg_, 1890. [818] Kahane, _Korrespondenzbl. f. Schweiz. Aezte_, 1907, viii. 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] Girard[821] and Blanchard[822] all found changes in the mucous membrane of the gut, showing that the parasites had been in the gut for a considerable time. Kahane[818] 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. [819] Schulze, _Deutsch. med. Wochenschr._, 1905. [820] Vix, _Zeitschr. f. Psychiat._, xvii. [821] Girard, _Annal. d. l’Inst. Pasteur_, 1901. [822] Blanchard, _Acad. de Méd._, July 3, 1906. [823] Poledne, _Wien. med. Wochenschr._, 1906. [824] Rippe, _St. Petersb. med. Wochenschr._, 1907. 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[825] obviously used too much benzine (1 dessert-spoonful to 1 litre of water), for severe irritation was set up, whilst Peiper[826] 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). [825] Becker, _Deutsch. med. Wochenschr._, 1902. [826] Peiper, quoted by Seifert, _loc. cit._, p. 248. 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[827] observations. [827] Merkel, “Handb. d. Therap. v. Pentzoldt-Stintzing,” i. 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] Babes[830]). 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. [828] Klopsch, quoted by Babes. [829] Langenbeck, _ibid._ [830] Babes, _Centralbl. f. Bakt._, 1906, xlii. 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[831] (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[832] also observed in trichinosis the constant appearance of a remarkably strong positive diazo-reaction of the urine. [831] Schleip, _Deutsch. Arch. f. klin. Med._, lxxx. [832] Stäubli, _ibid._, lxxxv. 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[833] 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[834] 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. [833] Moscato, quoted by Predtetschensky, _Zeitschr. f. klin. Med._, xl. [834] Stuertz, _Ges. d. Charité-Aerzte in Berlin_, June 26, 1902. *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[835]). 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. [835] Löbker and Bruns, _Arb. aus. dem. kaiserl. Gesundheitsamte_, 1906, xxiii. 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[836] 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. [836] v. Ziemssen, quoted by Haenisch, “Diss. Strasburg,” 1901. [837] Huppertz, quoted by Haenisch, “Diss. Strasburg,” 1901. 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[838]), the eosinophile cells increase considerably (Boycott,[839] Lohr[840]), yet in regard to diagnosis eosinophilia cannot be regarded as of equal value to a microscopical examination of the fæces (Bruns, Liefmann, and Meckel[841]). 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. [838] Baravalle, _Progresso medico_, 1903. [839] Boycott, _Journ. of Hygiene_, 1904. [840] Lohr, _Zeitschr. f. Heilk._, xxvi. [841] Bruns, Liefmann and Meckel, _Münch. med. Wochenschr._, 1905. 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[842]), or from putting food into the mouth with dirty hands. Looss[843] 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 Dieminger[845] 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[846]); 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[847]). [842] Inouye, _Arch. f. Verdauungs Krankh._, 1905, xi. [843] Looss, “Handb. f. Tropenkrankh.,” v. Mense, i, p. 129. [844] Schaudinn, _Deutsch. med. Wochenschr._, 1904. [845] Dieminger, _Klin. Jahrb._, 1905, xiv. [846] Dubreuilh, _La Presse méd._, 1905, xxx. [847] Goldmann, _Wien. med. Presse_, 1905, ii. 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[848]). [848] _Ibid._, “Die Hygiene des Bergmannes.” Halle: W. Knapp, 1903. (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 Dieminger[851] recommend washing out with freshly prepared lime water with the addition of caustic soda; Calmette[852] and Manouriez[853] 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[854]). 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[855] 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[856] 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. [849] Tenholt, _Münch. med. Wochenschr._, 1905. [850] Goldmann, _Wien. med. Wochenschr._, 1905, x. [851] Dieminger, _loc. cit._ [852] Calmette, _Acad. de Méd._, July 25, 1905. [853] Manouriez, _Bull. de. l’Acad. de Méd._, 1905. [854] Looss, _Zeitschr. f. klin. Med._, 1905, lviii. [855] Manson, _Brit. Med. Journ._, November 5, 1900. [856] Fabre, _Progrès méd._, 1905. Among the usual remedies for the expulsion of ancylostomes thymol certainly comes first, introduced by Bozzolo[857] 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] Smith[860]) or cascara sagrada (Mann[861]), 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[862]), 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[863] 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’s[866] 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. [857] Bozzolo, _Giorn. del R. Acad. d. Med. di Torino_, 1881. [858] Lutz, _Centralbl. f. Bakt._ [859] Grünberger, _Wien. med. Wochenschr._, 1902, lii. [860] Smith, _Amer. Journ. Med. Sci._, 1903. [861] Mann, _Deutsch. Arch. f. klin. Med._, lxxiv. [862] Prowe, _Virch. Arch._, clviii. [863] Sandwith, quoted by Looss. [864] Thornhill, _ibid._ [865] Leichtenstern, _Deutsch. med. Wochenschr._, 1887. [866] Grünberger, _loc. cit._ The combination recommended by Goldmann[867] 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[868] and Liermberger[869]). [867] Goldmann, _Ges. f. innere Med. in Wien_, March 8, 1906. [868] Goldmann, _Wien. med. Wochenschr._, 1905, x. [869] Liermberger, _Berl. klin. Wochenschr._, 1905. 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] Bauer[871]); Leonardi[872] speaks well of thymol essence (4·0 c.c. per diem) in an emulsion with plenty of water. [870] Pool, _Med. Woche_, 1901. [871] Bauer, _Wien. klin. Wochenschr._, 1904. [872] Leonardi, _Gaz. d. Osp._, 1904. 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[873]), whilst the reverse is frequently observed (Grünberger[874]). Nagel[875] 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[876] prefers extract. filicis maris (freshly prepared) to all other drugs. Warburg[877] 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[878]). Opinions are divided as to the combination of thymol and extractum filicis maris (Hynek,[879] Stockman,[880] Boycott and Haldane,[881] Adams[882]). As regards other remedies, eucalyptus oil is well spoken of by Philips[883] and Hermann[884]: 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[885] 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[886] 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] Liermberger[888]) are suitable. [873] Mann, _loc. cit._ [874] Grünberger, _loc. cit._ [875] Nagel, _Deutsch. med. Wochenschr._, 1903. [876] Zinn, “Therap. der Gegenwart.,” 1903. [877] Warburg, _Münch. med. Wochenschr._, 1904. [878] Nagel, _loc. cit._ [879] Hynek, _Sbornik Kliniky_, v. [880] Stockman, _Brit. Med. Journ._, 1904. [881] Boycott and Haldane, _Journ. of Hyg._, ix. [882] Adams, _Arch. of Pediat._, 1901. [883] Philips, _Lancet_, 1906. [884] Hermann, _La méd. moderne_, 1905. [885] Neumann, _Deutsch. med. Wochenschr._, 1904. [886] Bentley, _Indian Med. Gaz._, 1904. [887] Goldmann, _Deutsch. Aerzte-Zeitg._, 1903. [888] Liermberger, _loc. cit._ *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[889] 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. [889] Clason, _see_ Seifert, _Deutsch. med. Zeitg._, 1885. 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[890] 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[891] 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[892] collected fifty-nine cases relating to the invasion by _Ascaridæ_ of the bile-ducts and passages, and Dauernheim’s[893] 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 Schupper[895] (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. Epstein[897] 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 Vierordt[899] 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[900]), and gain access to the gall-bladder, the hepatic duct and its branches. [890] Sick, “Diss. Tübingen,” 1901. [891] Sick, _ibid._, 1901. [892] Borger, “Diss. München,” 1891. [893] Dauernheim, “Diss. Giessen,” 1900. [894] Neugebauer, _Arch. f. klin. Chir._, 1903, lxx. [895] Schupper, _Gaz. d. Osp._, 1904, xxxiii. [896] Schiller, _Beitr. zur klin. Chir._, 1902, xxxiv. [897] Epstein, _Deutsch. Arch. f. klin. Med._, 1904, lxxxi. [898] Mertens, _Deutsch. med. Wochenschr._, 1898, xxiii. [899] Vierordt, Volkmann’s _Samml. klin. Vortr._, No. 375. [900] Quincke, “Nothnagel’s Spez. Path. u. Therap.,” 1899, xviii. 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] Saltykow[902]). Leer[903] 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[904] 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. [901] Dauernheim, _loc. cit._ [902] Saltykow, _Prag. Zeitschr. f. Heilk._, 1900. [903] Leer, _Brit. Med. Journ._, 1906. [904] Vierordt, _loc. cit._ 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[905]) without giving rise to special symptoms. For example, Troja[906] found in the frontal sinus of a cadaver a large coiled-up Ascaris which occupied the whole cavity. Wrisberg[907] made the same observation in the cadaver of a boy. Deschamps[908] and Fortessin[909] 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. [905] Mosler and Peiper, “Nothnagel’s Handb.,” 1894, vi. [906] Troja, Napoli, 1771. [907] Wrisberg, _see_ Blumenbach, Göttingen, 1907. [908] Deschamps, _see_ Blass, “Diss. Strasburg,” 1902. [909] Fortessin, _see_ Bardeleben, “Lehrb. d. Chirurgie,” 1875. [910] Albrecht, _Commer. Noricum. T. I. Annal._, 1739. [911] Benievini, “Prol. Anat. d. Sin. front.,” Göttingen, 1779. [912] Forest, _see_ Tiedemann, Mannheim, 1844. [913] Lanzoni, _idem_. [914] Langelott, _idem_. [915] Tulpe, _idem_. [916] Reisel, _idem_. [917] Fehr, _idem_. [918] Bruckmann, _Commer. Noric._, 1739. [919] Bahr, _idem_. [920] Slabber, _idem_. [921] Lange, “Blumenbach’s Med. Bibl.,” Göttingen, 1788. [922] Chiari, “Krankh. d. Nase,” 1902. [923] Haffner, _Berl. klin. Wochenschr._, 1880. Among the rarer causes of the occurrence of strange bodies in the pharynx and naso-pharyngeal cavity, Jurasz[924] 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[925] and Wagenhäuser[926]; in the case recorded by Turnbull[927] (girl, aged 8, with pains in her ear) the Ascaris apparently reached the external auditory meatus by the same route. [924] Jurasz, Heymann’s “Handb. d. Laryngol. u. Rhinol.,” iii. [925] Reynolds, _Lancet_, 1880. [926] Wagenhäuser, _Arch. f. Ohrenheilk._, 1889, xxvii. [927] Turnbull, _Virchow-Hirsch Jahresbericht_, 1880. 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[928] records a fatal attack of choking from _Ascaridæ_ in the trachea. In a case recorded by Smyly[929] 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[930] collected twenty-five observations of invasion of the larynx and trachea by Ascaris. Mosler[931] reports the case of a patient with aphonia and dyspnœa from whose larynx an Ascaris was removed. Donati[932] reports a case of four Ascarides in the larynx, and Cerchez[933] of asphyxia from Ascarides in the larynx or trachea. Wagner[934] 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[935]; 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[936] 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. [928] Oesterlein, _Deutsch. Klin._ 1851. [929] Smyly, _Dubl. Journ._, 1867. [930] Fürst, _Wien. med. Wochenschr._, 1879. [931] Mosler, quoted by Liesen. [932] Donati, _Ann. Univ. de Méd. et Chir._, Milano, 1875. [933] Cerchez, _Clinica_, 1891, iv. [934] Wagner, _Deutsch. med. Wochenschr._, 1902. [935] Rabot, _Soc. de Sci. méd. de Lyon_, September 9, 1904. [936] Negresco, _Soc. de Méd. légale_, November 9, 1903. The route by which _Ascaridæ_ obtain access to the urinary passages must remain undecided. Schlüter[937] 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). [937] Schlüter, _Münch. med. Wochenschr._, 1902. 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[938] 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. [938] Epstein, _see_ Seifert, “Lehrb. d. Kinderkrankh.,” p. 273. 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[939] has issued a warning against the consumption of unboiled or badly washed vegetables, salad, strawberries, etc., and also against drinking polluted water. [939] Metschnikoff, _Gaz. hebd. de Méd. et Chir._, 1901. 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[940] 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). [940] Guermonprez, _see_ Seifert, _Deutsch. med. Zeitg._, 1885. 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[941] 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 Henoch[943] 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. [941] Küchenmeister, _loc. cit._ [942] Lewin, _see_ Seifert, _Deutsch. med. Zeitg._, 1885. [943] Henoch, _idem_. 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[944] 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] Hausmann[946]), also β-naphthol up to 0·45 grm. three times daily (Du Bois[947]), 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. [944] Schidlowsky, _see_ Seifert. [945] Calderone, _idem_. [946] Hausmann, _St. Petersb. med. Wochenschr._, 1900. [947] Du Bois, _see_ Lenhartz in “Penzoldt-Stintzing’s Handbuch,” p. 619. (Ferran[948]), filmaron oil 1·0 to 2·0 to 3·0 grm. in gelatine capsules, according to age (Bodenstein[949]). Brüning[950],[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. Thelen[952] appears to have had good results from this drug. [948] Ferran, _idem_. [949] Bodenstein, _Wien. med. Presse_, 1906. [950] Brüning, _Med. Klin._, 1906. [951] _Idem_, _Deutsch. med. Wochenschr._, 1907. [952] Thelen, “Diss. Rostock,” 1907. 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[953]). 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[954]). The conditions recorded by von Wagener[955] and Ruffer[956] 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. [953] Ungar, _see_ Seifert, “Lehrbuch der Kinderkrankh.,” p. 246. [954] Trendelenburg, _see_ Seifert, _idem_. [955] von Wagener, _Deutsch. Arch. f. klin. Med._, lxxxi. [956] Ruffer, _Brit. Med. Journ._, 1901. 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 (Majochi[958]), 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] Barbagallo[962] 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. [957] Seifert, “Lehrb. d. Kinderkrankh.,” and Lesser’s “Encyklop. d. Haut-u. Geschlechtskrankh.,” p. 373. [958] Majochi, _Boll. d. Sci. med. d. Bologna_, 1893. [959] Szerlecky, _Journ. Ann. Med. prat._, Paris, 1874. [960] Michelson, _Berl. klin. Wochenschr._, 1877, xxxiii. [961] Majochi, _loc. cit._ [962] Barbagallo, _Gaz. d. Osp._, November 16, 1900. [963] Vignolo-Lutati, _Arch. f. Derm._, lxxxvii, pt. 1. 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[964]) (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[965] 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[966]; 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[967] 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[968] 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. [964] Zarniko, “Die Krankh. d. Nase, u.s.w,” S. Karger, Berlin, 1905. [965] Chiari, “Erfahr. auf d. Gebiete der Hals- u. Nasenkrankh.,” Wien, 1887. [966] Hartmann, _Naturforscherversamml._, Köln, 1889. [967] Rheins, “Der prakt. Arzt.,” 1893. [968] Proskauer, _Zeitschr. f. Ohrenheilk._, 1891. 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[969] 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[970]). With regard to the second point, one has to observe strict cleanliness in general (Barbagallo[971] found ova of the parasites in the layer of dirt under the finger-nails). [969] Metschnikoff, _Med. Klin._, 1907, xlii, p. 1284. [970] Heller, _Deutsch. Arch. f. klin. Med._, lxxvii. [971] Barbagallo, _loc. cit._ 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). Dornblüth[973] employs the same medicament in a form only slightly modified from Ungar’s method, Barbagallo[974] 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. [972] Ungar, _see_ Seifert, “Lehrb. d. Kinderkrankh.” [973] Dornblüth, _Arztl. Zentral-Anzeiger_, 1903. [974] Barbagallo, _loc. cit._ 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] Still[976]), 1/2 per cent. salicylic acid solution or liq. alum. acet. (one tablespoonful to a litre of water, Dornblüth[977]), or gujanosol (2 to 3 to 4 to 5 per cent. solution, Rahn[978]). 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. [975] Heller, _loc. cit._ [976] Still, _Brit. Med. Journ._, 1899. [977] Dornblüth, _loc. cit._ [978] Rahn, _Münch. med. Wochenschr._, 1905. [979] Senger, _Berl. klin. Wochenschr._, 1907, xxxviii. 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[980]). 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. [980] Seifert, _Deutsch. med. Zeitg._, 1885. [981] Esser, _Schweiz. Korrespondenzbl._, 1893. 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. *HIRUDINEI* (Leeches). The only one of the leeches that comes under consideration from the clinical point of view is _Limnatis nilotica_ (_Hæmopsis sanguisuga_), which obtains access to the mouth with drinking water, and becomes lodged, even in the case of man, in the pharynx, larynx, trachea, œsophagus and nose. Amongst the causes of severe hæmorrhage from the pharynx Jurasz[982] mentions the occurrence of leeches in that region: in Northern Europe this must be accounted one of the greatest of rarities, whilst at all times in southern countries, such as South Italy, Spain, Greece, Algiers, Tunis and Egypt, it appears to have been more frequent. Even the physicians of antiquity had much to say about it. Upon the occurrence of blood-stained expectoration, Hippocrates recommends the oral cavity to be examined to see whether a leech is not present in it. Galen speaks of hæmatemesis due to the presence of leeches in the pharynx and stomach. Similar mention is found in the writings of Celsus, Asclepiades, Scribonius Largus, Dioscorides, Aëtius, Oribasius, Paulus Aegineta and others. In recent times, Cortial[983] has published observations relating to this subject which he had the opportunity of making in Constantine. Palazzolo[984] also in Sicily found leeches in two cases in the pharynx, in one case on the posterior wall, in the other in the crypt over the left tonsil. According to Roset,[985] leeches adhere by preference behind the uvula, simulating hæmatemesis and hæmoptysis, and the persistent hæmorrhages they give rise to may lead to severe anæmia. Leeches are found in still greater frequency in the larynx than in the pharyngeal cavity. Huber[986] records several observations of this kind in his historical and therapeutical study. In the case of a man, aged 64, Ramon de la Sota y Lastra[987] observed a leech on the nodulus epiglottidis; this was removed with the forceps. In the case recorded by Photiades,[988] a leech had remained adherent to the vocal cord for more than twenty-two days. Maissurianz[989] records two such cases: in one the leech had remained in the sinus morgagni for three weeks, in the other in the same place for ten days. The case recorded by Schmolitschew[990] is an interesting one; it was that of a woman who for four days had suffered from violent hæmoptysis, the cause of which was a leech that was fixed on the laryngeal wall of the epiglottis close above the vocal cords. In his case (that of a soldier), Godet[991] was forced to perform thyrotomy to remove the leech from the larynx. Ficano[992] removed a live leech with the forceps from the lower laryngeal cavity in a man, aged 30. Massei[993] reports a similar case. The case reported by Winternitz and Karbinski[994] was that of a peasant girl, aged 16, who suffered from coughing, hoarseness, and blood-stained expectoration; a leech had lodged on the root of the epiglottis. Aubert[995] removed a leech from the larynx of a woman after the performance of tracheotomy. Seifert[996] reports three cases: in the first the leech had become fixed to the left vocal cord, in the second it was found in the lower laryngeal cavity, and in the third on the border of the left ligamentum aryepiglotticum. Leone[997] has published the case of a leech in the larynx, Martin[998] two cases with the leech lodged in the lower laryngeal cavity, Berthoud[999] a similar case, Palazzolo[1000] two such cases, Panzat[1001] one case (lower laryngeal cavity). Moucharinski[1002] reports a case in which the leech had stayed more than twenty days in the larynx. Martin[1003] easily removed a leech from the posterior portion of the vocal cord with the forceps. Vieus and Nepeon[1004] record a case of a leech in the larynx. It is quite exceptional for leeches to gain access to the trachea; cases of this kind have been recorded by Aubert,[1005] Vicano,[1006] Ridola[1007] and Tapin[1008] (the leech was firmly fixed to the bifurcation and caused coughing, hæmoptysis and attacks of asphyxia; it was easily removed by the aid of a tracheal tube). Now and then leeches are found in the nose. [982] Jurasz, Heymann’s “Handb. d. Laryng. u. Rhinol.,” 1899, ii. [983] Cortial, _Union méd._, 1886. [984] Palazzolo, _Bull. del. mal. dell’ orecchio, etc._, 1895. [985] Roset, _Rev. d. Cienc. méd. de Barcelona_, 1907, ii. [986] Huber, _Deutsch: Arch. f. klin. Med._, xlvii. [987] Ramon de la Sota y Lastra, _Rev. méd. de Sevilla_, 1883. [988] Photiades, _Int. Zentralbl. f. Laryng._, 1884. [989] Maissurianz, _St. Petersb. med. Wochenschr._, 1883. [990] Schmolitschew, _Wratsch_, 1884. [991] Godet, _Arch. de Méd. et Pharm. milit._, 1887. [992] Ficano, _Rev. de Laryng._, 1890. [993] Massei, _Int. Journ. of Laryng._, 1890. [994] Winternitz and Karbinski, _Prag. med. Wochenschr._, 1890. [995] Aubert, _Echo méd._, 1891. [996] Seifert, _Rev. de Laryng._, 1893. [997] Leone, _Boll. del. mal. dell’ orecchio, etc._, 1892. [998] Martin, _Arch. de Méd. et Pharm. milit._, 1891. [999] Berthoud, _ibid._, 1893. [1000] Palazzolo, _Boll. del. mal. dell’ orecchio_, 1895. [1001] Panzat, _Arch. de Méd. et Pharm. milit._, 1896. [1002] Moucharinski, _Wratsch_, 1896. [1003] Martin, _Rev. barcelon de enf. de oido_, 1906. [1004] Vieus and Nepeon, _Monatsschr. f. Ohrenheilk._, 1884. [1005] Aubert, _Echo méd._, October 12, 1891. [1006] Vicano, _Boll. del. mal. dell’ orecchio, etc._, 1892, ix. [1007] Ridola, _Arch. ital. di Laryng._, 1894, ii. [1008] Tapin, _Siglo med._, March 16, 1907. Lusitanus[1009] relates the case of a man who suffered from severe headaches. A medical man ordered the application of a leech to the anterior portion of the nostril. Owing to the carelessness of the surgeon the leech crawled right into the nose; it was impossible to extract the leech or to kill it, and it produced a severe hæmorrhage which led to the death of the patient within two days. In a case recorded by Sinclair,[1010] a leech, _Hæmopsis sanguisuga_, gained access to the nose of a boy, aged 3; it remained there a fortnight; it caused frequent attacks of epistaxis and in the end it was removed by means of forceps. Condorelli-Francaviglia[1011] records a case in which severe epistaxis was caused by a leech which had probably entered the anterior portion of the left nostril by way of the pharynx and become tightly fixed there. It was seen by posterior rhinoscopy, and was removed from in front by means of slightly curved forceps. Sota y Lastra[1012] mentions the occurrence of leeches in the nose, and Keng[1013] reports the case of nasal obstruction from a leech. The removal of leeches is effected by means of injections or by the direct sprinkling of salt or acid solutions on their bodies, which brings about their detachment. When possible a previous attempt should be made to seize them with forceps so as to make their immediate extraction possible. The species of Hæmadipsa (Looss[1014]) live in tropical regions in moist places on the ground or in the jungle. They climb bushes and even trees with astonishing rapidity upon the approach of larger animals and also of man (whom they clearly recognize from the vibration of the ground caused by footsteps). From thence they let themselves fall on their victims to suck their blood. Their bites are generally painless, and of themselves not dangerous, but if they are unusually numerous they rapidly accumulate on the body in large numbers and give rise to marked debility and, if the wound become infected, to severe complications and even death. On the other hand, under careful treatment the wounds heal easily and fairly rapidly. [1009] Lusitanus, _see_ Seifert in Heymann’s “Handb.,” p. 599. [1010] Sinclair, _Brit. Med. Journ._, June 20, 1885, i. [1011] Condorelli-Francaviglia, Spallangini, 1892. [1012] Sota y Lastra, _Rév. méd. de Sevilla_, 1887. [1013] Keng, _Scot. Med. and Surg. Journ._, October, 1899. [1014] Looss, “Handb. d. Tropenkrankh.,” v. Mense, i, p. 194. Firm leather and firmly adhering clothes afford no certain protection against the attacks of these leeches, as they know how to force themselves with extraordinary rapidity through the narrowest interstices between the clothes and thus gain access to the skin. When they have sucked their fill--and this may take several hours to accomplish--they fall off of themselves. To effect an earlier removal drops of irritative or corrosive fluids are employed (salt solutions, acids, etc.). Tearing away the leech by force should be avoided, as in this way portions of the leech’s body may be left behind in the wound and inflammation be set up. ARTHROPODA. *Leptus autumnalis* (Grass, Harvest, or Gooseberry Mite[1015]). In the hot season of the year, that is, during the months of July and August, it is noticed that those people who stray amongst syringa bushes or who pick gooseberries or kidney beans are attacked by the _Leptus autumnalis_. On the uncovered parts of the body there appear numerous red spots and papules, which itch and burn smartly. The itching does not commence diffusely, as in the case of scabies (MacLennars[1016]), but is limited to the particular points where the parasite is situated. There are especial outbreaks of itching in the morning, arising perhaps from the hatching of ova in the host after lying in the warmth of the bed.[1017] Leptus frequently provokes general erythema, eczematization or severe feverish urticaria, which in France is known by the name of fièvre de grain (Mégnieu, Besnier[1018]). If the individual efflorescences be carefully examined, there will be noticed almost without exception a minute boss towards the centre, noticeable by its yellowish-red colour. If an attempt is made to remove it with the point of a needle or to scrape it off the surface, one can often perceive, even with the naked eye, a small reddish creature moving actively about. The treatment of these very troublesome symptoms consists in warm baths with soapy lavages, also lavages with alcohol, spirit salmiac (G. P.), 5 per cent. carbol or creolin solution, diluted vinegar, benzine, emulsions of balsam of Peru, rubbing in sulphur ointment (Sandwith[1019]); ointments of creosote or eucalyptus are recommended. Other grass and grain mites also occasionally penetrate the skin of man and produce transitory but sometimes very severe eruptions, urticaria and eczema papulosum, as Geber[1020] and subsequent to him Josai[1021] have reported of the barley mite. In sensitive individuals the skin becomes bright red, to a greater or less extent their temperature is raised and frequently slight febrile affections are present. If the inflammatory skin symptoms have reached their culminating point after three or four days and no fresh complications arise, they only remain for a short while, the effects of scratching and pigment spots being left. [1015] There is no reason for calling this the gooseberry mite. It is rarely found on this fruit. The gooseberry mite is _Bryolia pretiosa_. [1016] MacLennars, _Lancet_, 1905. [1017] [This cannot be the case, as _Leptus autumnalis_ is the larval form of _Trombidium holosericeum_.--F. V. T.] [1018] Sack, “Handb. d. Hautkrankh.,” v. Mraček, 1907. [1019] Sandwith, _Lancet_, 1905. [1020] Geber, “Handbuch d. Hautkrankh.,” in v. Ziemssen’s “Handbuch d. spez. Pathol. u. Therap.,” 1884, xiv. [1021] Josai. *Kedani, Akaneesch* (The Japanese River or Inundation Disease). This disease is only known in Japan, and is limited to the neighbourhood of some great rivers on the west coast. The people mostly attacked are those who cut the hemp harvest in the infected localities, occasionally those who transport it or come into contact with it (Looss[1022]). The disease is frequently manifested in the form of indefinite disturbances of the general condition; it commences generally on the sixth day after the presumed infection with rigors, headaches, feeling of weakness, swelling of the lymphatic glands in the loin or in the arm-pits; in the periphery a black dry scab is formed. In addition there is an intense conjunctivitis, and added to symptoms of fever an exanthema resembling measles that lasts from four to seven days. There is frequent delirium and difficulty of hearing which persist for a long while. Obstinate constipation is a striking symptom. At the end of a fortnight, earlier in slighter cases, the fever commences to abate and a rapid convalescence sets in. In pregnant women abortion with fatal issue is frequent. With regard to prophylaxis, Baelz[1023] recommends as rapid a cultivation of the soil as possible, which has led to a speedy disappearance of the disease in districts where it was once dreaded. Treatment is symptomatic. Japanese do not tolerate antipyretic drugs as well as Europeans. [1022] Looss, “Handbuch d. Tropenkrankh.,” v. Mense, p. 195. [1023] Baelz, _Virchow’s Archiv_, lxxviii. Dermanyssus gallinæ (avium). During the day the resort of bird mites is in the droppings and in the woodwork, etc., of cages in which canaries, crossbills and parrots are kept; in the crevices of doors, in the chinks between the board planks of bedsteads, so that at night they may seek some domestic animal to suck the blood and so satisfy their hunger. It is by no means rare for young animals, chickens and unfledged pigeons, etc., to perish in consequence of the great loss of blood. This nocturnal habit of life explains why no mites can be found during the day in spite of the most careful examination of the human body, to which they may be transmitted. On the uncovered parts of the body they not only cause severe irritation, but also severe diffuse itching erythema and eczema. Thorough disinfection of the cages by hot solution of caustic potash, in addition, sprinkling over with tar, red carbolic acid or petroleum, thoroughly powdering over the birds with flores pyrethræ, washing with water containing oleum anisi, washing the walls, doors and bedsteads with soap, disinfection of the mattresses, linen and clothes, will protect against further infection. In the case of man the disease needs no special treatment, as the eruptions generally disappear after some days. Heinecke[1024] recommends lavages with 1 per cent. carbolic acid solution. [_Vide_ also p. 492 in body of this work.--F. V. T.] [1024] Heinecke, _Münch. med. Wochenschr._, 1901. [_Dermanyssus hirundinis_, Hermann, is identical with this species. By far the best treatment is with paraffin or kerosene oil applied to the places where they pass the day.--F. V. T.] Ixodes reduvius (ricinus). The female is occasionally transmitted to the human skin, and bores its proboscis deep into it and sucks itself full of blood. At sensitive points of the cutaneous surface--for example over the skin of the penis--a feeling of severe pain is produced. Buy’s[1025] observations as to the geographical distribution of the _Ixodinæ_ show that in all lands in which cattle, horses, sheep and dogs exist, _Ixodinæ_ are to be found. Recent observations show that the _Ixodinæ_ play an important part in the transmission of Hæmosporidia (_vide_ body of work, pp. 493, 494). Sprinkling with oil, vaseline, benzine, ether, petroleum, naphtha, turpentine (Jelgenum[1026]), will easily lead to the removal of the parasite; if the body is torn away with violence and the proboscis is left sticking in the skin, the presence of the latter will give rise to inflammation and suppuration. [1025] Buy, “Histoire naturelle et médicale des Ixodes,” “Thèse de Lyon,” 1906. [1026] Jelgenum, _Med. Weekblad v. Noord- en Zuid-Nederland_, 1901, i, No. 24. *Sarcoptes scabiei* (Scabies). The disease produced by _Sarcoptes scabiei_ shows itself in polymorphous areas, such as accompany eczema, and are produced on the one hand by the Sarcoptes alone and on the other hand by the scratching with the nails. The localization of both kinds of efflorescences is different from those which are produced by the Sarcoptes; they occur as papules, vesicles, pustules and mite-tracks, and their usual situation is between the fingers, on the ulnar border of the hand, on the wrist, on the palm of the hand, on the anterior border of the axilla, on the penis and at the base of the thorax. The excoriations are situated on the forearm, over the thigh, over the abdomen, and may be distributed in greater or less degree over the whole body; the back and the face only remain free. The symptoms consist in violent itching, the onset of which specially takes place at night. The mite-tracks are fine curving lines, curved like *a*, *u*, *c*, or *s*, which appear as if they had been scratched with a fine needle. Upon closer examination with the magnifying glass one sees in their course small openings. These openings, in persons who keep themselves clean, are scarcely coloured; but in patients whose occupations necessitate their being associated with coloured or dirty substances, they are dark. The length of the tracks varies from some millimetres to 1-1/2 to 2 cm. They are at the one end, where the Sarcoptes is embedded in the epidermis, widened like a funnel and slightly exfoliated. The track at this point is sharply defined; the mite shows through the epidermis as a yellowish round point. In the course of the track there develop papulæ, vesicles or pustules, which raise the level of the track. The intensity of these inflammatory appearances depends upon the susceptibility of the human individual and upon the capability of the reaction of the skin. There are people in whom scarcely any inflammatory symptoms make their appearance; on the other hand there are some, especially children and lymphatic individuals, in whom severe impetiginous ecthymatous pustules, together with their sequelæ, are set up. The results produced by scratching consist in papules, which usually bear a small scab of blood, and are arranged in the form of striæ, in eczematous surfaces, weeping or sanguineous scabs, vesicles, pustules, etc. The complications that set in are frequently urticaria and even furuncles, lymphangitis and inflammation of the glands, which now and then is followed by the formation of abscesses in the glands. The duration of the disease is unlimited; when untreated it leads to a form of rare occurrence, that of scabies norvegica[1027]; in this the collection of crusts and scales, in which a quantity of dead mites, larvæ and ova are present, may become colossal. [1027] [This is produced by a distinct species, _vide_ pp. 519–20.--F. V. T.] The symptoms of scabies abate in the presence of intercurrent acute diseases and reappear after the malady is over. The fact has for long contributed to the idea of scabies being regarded as a disease capable of being “driven in” upon the internal organs and forming metastases. The diagnosis is rendered certain upon the discovery of a track. Traces of scratching on the extremities and on the abdomen, papular or pustular efflorescences between the fingers, toes, in the neighbourhood of the wrist, of the elbow, on the anterior border of the arm-pit, on the tuber ischii, in the girdle region, and especially the presence of disintegrated tracts over the penis (prepuce and glans), will allow of the diagnosis being made. Certain occupational eczemas (grocers, lime-workers, maltsters, bakers and others), also prurigo, must be borne in mind when diagnosing this disease. The prognosis is always a favourable one. Even after such a long duration and after such severe symptoms the disease may completely clear up. There are, however, frequently left behind post-scabious inflammatous and pruriginous conditions which only yield after protracted treatment. Scabiophilia, which persists in certain patients for a long time after the scabies has been cured, must here be mentioned. In the treatment of scabies four points must be kept in view. (1) The mites and the ova must be killed by the treatment; (2) the treatment must have regard to the intensity of the inflammatory symptoms; (3) the clothes (body-linen) of the patients must be disinfected; the bed-linen, the beds and the bedsteads must be cleansed; (4) when a person suffers from scabies his entourage must be examined, and all diseased conditions treated in the same way as under (3). The treatment (1) should be preceded by a bath with thorough soap ablution, and when the inflammatory symptoms are not too severe, with green soap. After the bath the skin is dried and the scabies remedy proper applied in warmth. Sulphur preparations receive first consideration; among such Vlemingkz’s mixture occupies a prominent position; this is rubbed in for half an hour by means of a strong camel-hair brush, to be followed by another bath and powder applications after drying. Repeat this method for three days one after the other, or for two days, and a third time eight days later. The latter method is worthy of recommendation as the ova, which perhaps resist the parasiticide action, have by this time developed into larvæ, and the latter can then be destroyed with certainty. The remaining sulphur preparations, which are specially employed in the form of ointments, are more complex, as the ointment should remain on the skin. Helmerisch’s and Wilkinson’s ointments are the kinds specially employed. Nagelschmidt[1028] recommends thiopinol as a very suitable sulphur preparation in the form of baths or as a 10 or 5 per cent. ointment in the following way: Upon his reception the patient is given a thiopinol bath, in which he remains for thirty minutes. Immediately afterwards 30 to 40 grm. 10 per cent. thiopinol vaseline is carefully rubbed in. The rubbing is repeated daily, and the treatment is concluded on the second to fourth day with a second thiopinol bath. Thiopinol produces no more irritation than the ordinary sulphur ointments; it is, however, much more penetrative and more capable of absorption. [1028] Nagelschmidt, _Med. Klin._, 1907, xxxv. We frequently make use of Kaposi’s naphthol ointment, as it renders the skin supple, causes proportionately little irritation, and has but little smell. Treatment with balsam of Peru is certainly expensive, but in the slighter attacks it is relatively the simplest. We give the patient a bath, have him thoroughly dried and rub in 30 to 40 to 50 grm. balsam of Peru carefully and evenly all over, wrap him in a covering of wool, and make him rest in bed for twelve to fifteen hours, to be followed by a bath with careful cleansing with soap; this treatment need rarely be repeated. The balsam of Peru can be applied undiluted for the rubbings or mixed with ung. glycerini, or resorbin or glycerine in equal parts. [Norman Walker uses balsam of Peru 1/2 oz. dissolved in rectified spirit; to be painted on with a brush.]--J. P. S. The manufacturers name the undiluted product of the active constituent of balsam of Peru, benzoic acid benzyl-ester, Peruscabin. For the treatment of scabies it is recommended by Sachs[1029] that it should only be administered when mixed with ricinus oil, under the name of Peru oil, in applications repeated three times within thirty-six hours. [1029] Sachs, _Deutsch. med. Wochenschr._, 1900. Sack[1030] also considers Peru oil a non-irritant, effectual, pleasant, inodorous and non-staining drug. But he only allows the applications to be used every twelve hours for three to four consecutive days (altogether 200 to 300 grm. of Peru oil are requisite), and after the sixth or seventh rubbing a bath should be taken with the use of Dutch soap. Juliusberg[1031] considers this treatment specially suited for private practice. Another modern drug is epicarin ([Beta]-oxy-naphthyl-ortho-oxy-meta-tolyol acid); this is applied in 10 to 20 per cent. ointments (Pfeiffenberger[1032]), epicarin 7·0 grm., cretæ alb. 2·0 grm., vasel. flavi 30·0 grm., lanolin 15·0 grm., axungia poric. 45·0 grm. (Rille[1033]); epicarin 15·0 grm., sapon. virid. 5·0 grm., axung. poric. 100·0 grm., cretæ alb. 10·0 grm. (Kraus[1034]); for children, epicarin 5·0 grm., lanolin 90·0 grm., ol. olivar. 10·0 grm. (Kaposi[1035]). Siebert[1036] lays stress upon the odourlessness and colourlessness of epicarin ointment as a strong reason for its use, and points out that it is a harmless drug, the action of which is certain. Endermol (salicylic acid ointment) has a destructive action on the mites even in a 0·1 per cent. ointment (Wolters,[1037] Demitsch[1038]); it is, however, very expensive and not wholly free from danger; and the same applies to nicotiana soap (Taenzer,[1039] Schumann[1040]). [1030] Sack, “Handb. d. Hautkrankh.,” v. Mraček. [1031] Juliusberg, _Therap. Monatsh._, 1901. [1032] Pfeiffenberger, _Klin. therap. Wochenschr._, 1900. [1033] Rille, “Die Heilkunde,” 1900. [1034] Kraus, _Allg. wien. med. Zeit._, 1900. [1035] Kaposi, _Wien. med. Wochenschr._, 1900. [1036] Siebert, _Münch. med. Wochenschr._, 1900. [1037] Wolters, _Therap. Monatsh._, 1898. [1038] Demitsch, _Wratsch_, 1905, iv. [1039] Taenzer, _Monatsh. f. prakt. Derm._, xxi. [1040] Schumann, _Allg. med. Central-Zeitg._, 1901. To give an account in detail of the drugs and methods--old and new--used in the treatment of scabies would far outrun the limits of this work. Demodex folliculorum. It is not yet certain whether the _Demodex folliculorum_ is capable of developing pathological conditions in man. Veiel[1041] assumes that the hair follicle mite has no connection either with the formation of comedones or even with sebaceous gland disease. Kaposi[1042] considers that they cause no disease in man and cannot be regarded as a cause of acne. Saalfeld[1043] clearly adheres to the same standpoint, similarly so Jessner,[1044] who, when discussing comedones, makes no mention of acne of hair follicle mites. Weyl[1045] and Geber[1046] adhere to the opinion that the presence of a Demodex in man in contradistinction to its presence in animals possesses absolutely no pathogenic influence. On the other hand de Amicis,[1047] Majochi,[1048] and Dubreuilh[1049] report single cases of pronounced circumscribed clear brown pigmentations which they attribute to _Demodex folliculorum_. In all these cases, moreover, as regards localization the affection had a certain resemblance to pityriasis versicolor; nevertheless, in the scales separated off with the scalpel no fungi were found, but on the other hand Demodices in moderate quantity. In his earlier cases Majochi has seen the Demodex in the secretion from meibomian glands and had claimed it to be the excitant of chalazion and, as Mibelli[1050] did, considered it to be the cause of some diseases of the eyelids. Ivers[1051] found the parasite in 69 per cent. of normal borders of the eyelids, and attributes a pathological signification to it. Hünsche[1052] and Mulder[1053] arrive at the same conclusions; in the light of their investigations the Demodex is found as a constant accessory--certainly not in the meibomian glands, as it is limited only to the internal part of the hair follicle. Lewandowsky[1054] considers that it can hardly be demonstrated at present that the same parasite which in individual specimens causes no symptoms is capable of producing pathological conditions when markedly increased in numbers. [1041] Veiel, v. Ziemssen’s “Handb. d. spez. Path. u. Therap.,” 1884, xiv. [1042] Kaposi, “Path. u. Therap. d. Hautkrankh.,” 1899. [1043] Saalfeld, Lesser’s “Encyclop. d. Haut- u. Geschlechtskrankh.,” 1900. [1044] Jessner, “Kompend. d. Hautkrankh.,” 1906, 3rd ed. [1045] Weyl and Geber, v. Ziemssen’s “Handb. d. spez. Path. u. Therap.,” 1884, xiv. [1046] Weyl and Geber, v. Ziemssen’s “Handb. d. spez. Path. u. Therap.,” 1884, xiv. [1047] de Amicis, quoted by Lewandowsky. [1048] Majochi, _Centralbl. f. Bakt._, xxv. [1049] Dubreuilh, _La Prat. Derm._, Paris, 1901. [1050] Mibelli, quoted by Lewandowsky. [1051] Ivers, _ibid._ [1052] Hünsche, _Münch. med. Wochenschr._, 1900, xlv. [1053] Mulder, _Weekbl. v. het Nederl. Tijdschr. v. Geneesk._, 1889. [1054] Lewandowsky, _Deutsch. med. Wochenschr._, 1907, xx. Treatment is by the removal of the comedones, above all, by their mechanical removal by pressure with a watch-key and with the various comedo-compressors, and by subsequent cleansing of the skin with ether, benzine or spirit. If the eyelids should be affected with blepharitis due to the presence of Demodex in large numbers, epilation and administration of a parasiticide is recommended. Demodex folliculorum canis. Transmission from dog to man is in any case very rare, and by many its occurrence is generally doubted. Nevertheless Gruby[1055] and Remak[1056] claim that it is transmissible--an opinion which has also been shared by Neumann[1057] and Zürn.[1058] The latter saw in the case of a married couple who had the care of mangy dogs the onset of diseased areas on their hands and feet, which were like those on the dogs and contained the same parasites. [1055] Gruby, quoted by Lewandowsky. [1056] Remak, _ibid._ [1057] Neumann, _ibid._ [1058] Zürn, _ibid._ A. Babes[1059] also reports several observations which go to show that persons who, to some extent, have been shown to have been in contact with mange-stricken dogs have been attacked by a scabies-like eruption localized over the thorax, abdomen, back and extremities; large numbers of Demodices were found in the follicular pustules. Lewandowsky[1060] reports one case--that of an Italian workman, who suffered from an outbreak on the face, like impetigo; there was crust formation and at the edge of the crusts the epidermis appeared like a narrow row or border of vesicles. A small portion of the covering of the row of vesicles was lifted off, and after slight warming examined in 40 per cent. liquor potassæ. In this a large number of animal parasites of the Demodex group were found, and without doubt _Demodex folliculorum canis_ alone. Hünsche[1061] assumes that _Demodex folliculorum_ penetrates into the tissues and produces abscesses. [1059] Babes, _ibid._ [1060] Lewandowsky, _Deutsch. med. Wochenschr._, 1907, xx. [1061] Hünsche, _Münch. med. Wochenschr._, 1900, xlv. Treatment first consisted in dusting with zinc amyl powder, but after four days there was no change. After the regular use of xeroform as a powder application, the affection cleared up within fourteen days. INSECTA. *Pediculus capitis* (Pediculus capitis) (Head Louse). We find _Pediculus capitis_ in very young children and in others more grown up to be the incessant and frequent cause of impetiginous crust-forming eczemas. It is more frequent in girls than in boys. In families it is endemic, in schools epidemic, but it also occurs in fair frequency in female adults (servant maids, waitresses) who may pay little attention to bodily cleanliness. The puncture of the parasites sets up a severe irritation, which leads to violent scratching. The consequences of this are the formation of nodules and pustules, crusts and “weeping” patches; the hairs become felted and the final clinical picture is that of plica polonica. The conditions of irritation which are produced by these parasites and then by the scratchings of the impetiginous, and frequently the very severe suppurative processes of the hair-bed, lead to swellings in the neck and sometimes even to glandular suppurations. The eczematous processes not infrequently extend over the face, the neck and the thorax. Blepharitis and conjunctivitis may be due to _Pediculus capitis_. The means of infection are often very remarkable. Transmission from one individual to another certainly often occurs, but infection may take place in railway carriages and in other ways. A case under the observation of a colleague in Frankfort is a most remarkable one: he diagnosed pediculosis as the cause of a head eczema occurring among the children of one of the best families there. The infection took place through dolls adorned with human hair, in which the presence of nits could be demonstrated. The diagnosis of _Pediculus capitis_ is not difficult to make when the hairs and hairy scalp are carefully examined for nits and living parasites. In better families it is a good plan to point out the _corpora delicti_ to their possessors and to make them aware of the possible sources of infection. As regards treatment, lotions of sabadill vinegar are recommended; in slighter cases these are quite sufficient. In severe cases cure will not result unless dressings of petroleum, naphthol ointment (5 to 10 per cent.) and balsam of Peru be applied. In the case of plica polonica, the hair must be cut quite short (even in adults) so as to control matting of the hair. To get rid of nits from hair that is not matted, careful combing and washing with strongly alkaline fluids or with hot vinegar is suitable. *Pediculus vestimenti* (Clothes Louse). The clothes louse attacks adults by preference, and with especial frequency old and emaciated persons. It lives in the clothes, but derives its nourishment from the body. At the moment at which the clothes louse inserts its proboscis into the skin the person experiences a slight sting, which, however, at once ceases to hurt. If the body of the louse is sucked full of blood it falls off and the individual has rest from it for a time. A wheal develops around the hæmorrhagic area of the bitten spot and itches severely. The itching goes on until the eruption is scratched all over. This is followed by crust formation. When many parasites are present the itching reflexes become more severe, and the patients scratch themselves considerably and make long marks at those places where the Pediculi have been. The localization of the scratching effects is characteristic, corresponding with folds between portions of clothing (regions between the shoulder-blades, wrist and neck). If the condition lasts for a month, the scratching effects extend over the whole body, and secondary efflorescences become associated with it, such as pustules, ulcers and eczemas. Intermediate between this we find cicatrices and pigmentation, the latter under certain circumstances extending over the whole body. Sulla, Herod, Cardinal Dupet, Philip II, and others are said to have died from louse disease. That even at present many human beings are exposed to the danger of being devoured by lice is a fact that we have had the opportunity of observing on several occasions. Only to record one instance, a man, aged 65, was received into our clinic some time ago in an absolutely neglected condition (he had been staying for some weeks in a stable, lying on a wretched bed). The whole of the surface of his body was covered with countless furuncles, of greater and less size, which had partly become changed into undermined ulcers. Over the ulcers and beneath their undermined edges Pediculi were swarming. *Phthirius inguinalis* (_Pediculus pubis_) (Crab Louse). The transmission of these parasites generally takes place during coitus, and therefore they especially occur in the pubes. It is possible also that transmission is effected through dirty clothes and bed-linen and privy seats.[1062] Starting from the pubes the animals crawl out over the other parts of the body provided with hairs to the abdominal wall and the thorax (so far as these parts are furnished with thick hair) to the arm-pits, the beard, the eyebrows; not, however, to the hair of the head, or rarely so; among our numerous cases we have never met with an example of the crab louse attacking the hair of the head. [1062] [A case of infection through a dirty station privy in Switzerland came to my knowledge in 1899, and numbers of pediculi were found there.--F. V. T.] The irritation produced by the crab louse is extraordinarily severe, especially during the night, as the warmth of the bed incites the lice to active sucking. In consequence of the violent scratching indulged in, eczemas are set up at the points attacked, and these often spread to the neighbouring parts not covered with hair. Of special interest is the onset of maculæ cæruleæ (tâches bleues) in some persons affected with crab lice (people disposed to sweating seem to be peculiarly liable to these). They consist in pale blue patches of various size and shape, varying from that of a hemp-seed to that of a lentil, and again to that of a nail in size and form. These are found over the cutaneous surface of the abdomen, thorax and thigh, and are often only seen by a good lateral illumination. Duguet[1063] considers that the condition is a toxic erythema, that it is set up, on the occasion of the bite of the parasite penetrating the skin, by the poisonous substance derived from it. Oppenheim[1064] considers that it is a colouring substance that is formed in the salivary glands of the parasites, and which penetrates the skin when the insects bite, and thus forms the maculæ cæruleæ. We have on several occasions emulated the experiment of Duguet (trituration in a mortar of crab lice freshly taken from the human body and inoculating the mass thus obtained beneath the skin), and have similarly been enabled to produce the maculæ cæruleæ experimentally, but we have certainly been unable to determine which of the hypotheses is the correct one, the toxic erythema or the colouring substance inhibition theory. [1063] Duguet, _Annal. de Derm._, II Sér., i. [1064] Oppenheim, “Handb. d. Hautkrankh.,” v. Mraček, 1907. The diagnosis of phthirasis is very easy, for either the sexually mature parasites or the nits are found on the hairs. As regards treatment, grey ointment is regarded as a generally useful application; it gives rise, however, to a slight eczema of the genitals, especially in males, when injudiciously used. Geber[1065] recommends petroleum or balsam of Peru, Oppenheim[1066] a 1 per cent. sublimate solution for lotions, or a mixture of equal parts of petroleum and benzine when the sublimate cannot be borne. The use of a 5 per cent. ointment with hydrarg. oxid. flavum is worth considering in treatment of pediculosis of the eyebrows and eyelashes. The simplest method of treatment, and one with a radical effect, is that by sulphuric ether recommended by Thomer.[1067] It certainly produces a sharp burning sensation, but the living parasites and nits are destroyed in one sitting. We prefer ether lotions as a rule, and we thoroughly rub the affected parts with a pad of wadding well soaked with the ether. The dead parasites and the nits fall on to what lies beneath when the rubbing is done thoroughly, and the burning sensation caused by the ether only lasts a few minutes. [1065] Geber, _see_ Seifert, Lesser’s “Encyclop.,” p. 387. [1066] Oppenheim, _loc. cit._ [1067] Thomer, _see_ Seifert, Lesser’s “Encyclop.,” p. 387. *Cimex (Acanthia) lectularia*[1068] (_Cimex lectularius_) (Bed Bug). [1068] _Vide_ genus Cimex, p. 534. The puncture in the skin made by the bed bug gives rise to an extraordinary amount of severe itching and a burning sensation, and when the skin is sensitive wheals of remarkable size (_urticaria ex cimicibus_). These eruptions that cause such severe itching are scratched by those attacked, till very soon blood begins to flow, and this generally leads to the formation of a dried crust of blood at the point of eruption. The diagnosis is not always easy, as urticaria arising in other ways frequently leads to similar vigorous scratching and formation of crusts of dried blood. Men who have some experience in this matter (for example, commercial travellers), when they are attacked by severe itching at night, are in the habit of striking a light and searching in their bed and body-linen for the bugs, in order to be able to hand over the _corpora delicti_ to the landlord if need be. The assumption that the bugs in the East play an actual part in the propagation of tuberculosis and bubonic plague has been proved by investigations made by Nuttall[1069] to be at least very exaggerated if not wholly without foundation. Further investigations may decide how far the bugs participate in the transmission of kala-azar, as is believed by Rogers to take place. [1069] Nuttall, _see_ Sack “Handb.,” v. Mraček, p. 290. The bed bugs must be exterminated by spraying the chinks and joints in the boards with petroleum and benzine, pulling up the carpets and cleansing the bedsteads. For the treatment of the bite itself the methods recommended as an antidote against insects’ stings in general are suitable: 2 per cent. carbol vaseline (Rosenbach[1070]), thymol dissolved in spirit (1 in 50[1071]), æthrol or deci-æthrol, form-æthrol (manufactured by Dr. Nordlinger, Flörsheim a. /M.), formol[1072] (formol 15 parts, xylol 5 parts, acetone 44 parts, Canada balsam 1 part), with the aid of a pad of wadding placed over the part bitten, lavages with vinegar, citron juice and spirit of salmiac. [1070] Rosenbach, _Therap. Monatsh._, 1903. [1071] _Leipzig. med. Monatsh._, 1907, vi. [1072] _Chemist and Druggist_, August 25, 1906. *Pulex irritans* (Human Flea). The bite of the flea produces a slight discharge of blood about the size of a pin’s head, which rapidly becomes surrounded with a circular area similar to a patch of roseola. The redness fades away after a longer or shorter while (several hours), whilst the discharge of blood is to be seen for one or two days longer. In dirty people the whole body may be covered with such discharges of blood. Individuals with very delicate, sensitive skin, especially small children, show true wheal formation at the site of the bite. In certain cases there develops from one such single bite an urticaria that extends over a large part of the body. The manner by which an irritating substance is introduced into the skin upon biting by the bed bug and also by the flea is clear. The bite is followed by a feeling of itching, which is liable to rob nervous persons of their sleep. Sensitive individuals are upset even by the fleas moving over the surface of the skin during their rest at night. Treatment consists in extreme cleanliness, capture of the parasites, sprinkling the body and bed-linen with insect powders. The fleas are difficult to remove from barracks, schools and hospitals. *Dermatophilus* (*Sarcopsylla*) *penetrans* (Sand Flea). The fertilized females penetrate into the skin with their heads, and here they swell, in consequence of the numerous and growing eggs and larvæ, to a white ball the size of a small pea, on which the head is recognizable only as a small brown point. In this way a small brown tumour arises, over which, at the commencement, the skin is not reddened; after some days, however, it becomes inflamed; in the centre of it a small opening is seen. If the parasite is not extracted the skin that lies over it becomes destroyed by suppuration, and thus becomes removed. At the commencement the part affected itches, with increasing inflammation; the symptoms of irritation become more severe and may amount to actual pain. If the small suppurative processes be neglected, inflammation and gangrenous and septic processes may arise. The region of the body sought out by preference by the sand flea is the sole of the foot, the toes, under the free ends of the nails and the digito-plantoid folds--more rarely the scrotum, thigh and other parts are attacked (Scheube[1073]). The number of parasites found on one person may amount to several hundreds. [1073] Scheube, “Die Krankh. d. warmer Länder,” 1896. Treatment consists in the removal of the parasites from the skin with a needle or a small sharp knife and the application of a bandage. Rubbing the feet with copaiba or Peru balsam, sprinkling them with insect powder, or washing them with bay rum (Berger[1074]) acts as a prophylactic or removes the irritation of the skin produced by the parasites. [1074] Berger, _Therap. Monatsh._, April, 1907. Myiasis. Under the name of myiasis we designate the complex symptoms which parasitic dipterous larvæ give rise to in man (Braun), and we conceive under the term myiasis externa (dermatosa s. cutanea) all lesions of the human integument caused by fly larvæ and of the cavities covered with mucosa therewith connected, such as the external auditory meatus, the oro-nasal cavity, the urethra and vagina. The occurrence of dipterous larvæ in the digestive tract is named myiasis intestinalia or interna. Myiasis externa. The larvæ of a species of fly belonging to the _Muscidæ_, _Lucilia macellaria_,[1075] are found in relative frequency in the nose, especially in America and India.[1076] Riley[1077] has stated that the screw-worm of Central America and of the United States is nothing else than the larva of _Lucilia macellaria_, and also that the Brazilian fly named “berna” may be no other than _Lucilia macellaria_. Their offspring may set up inflammatory disturbances in the soft tissues of man. This fly has a wide distribution, from the Argentine Republic to Canada, also in the British portions of the East Indies, where the disease is named “peenash.” This word is derived from the Sanskrit, and is said to be a collective name for all diseases of the nose. Lahory[1078] states that within a period of nine years ninety-one cases of “peenash” occurred in Allyghar, two of these ending fatally. _Lucilia macellaria_ is not at all timid but bold, like the house-flies and blue-bottles, its relatives. It not only lives at no great distance from human dwellings, and forces its way into villas and country houses, but even attacks its victims without awaking them from their sleep. Although this species shows a certain preference for nasal cavities affected with catarrh or pus (v. Frantzius[1079]), and also the external auditory meatus, as well as ulcerated or wounded parts of the body, and even badly ulcerated skin carcinoma (Lutz[1080]), it is not a rare thing for it to penetrate into one of the above-mentioned cavities rapidly to deposit its eggs, without these parts having been previously affected. The report also of Conil,[1081] in which these flies bear the name of _Calliphora anthropophaga_[1082] is an interesting one. Probably it was the same species of Muscid in the cases of myiasis nasi observed by von Tengemann, Delasiauve,[1083] Weber,[1084] Mankiewicz,[1085] and Kirschmann.[1086] In the case recorded by Prima,[1087] and in that recorded by Britton,[1088] the issue was a fatal one; in the latter the larvæ escaped through the pharynx and nose; the hyoid bone and the soft parts of the palate were destroyed, the speech and power of swallowing were hindered. At the _post-mortem_ extensive destruction of the internal nose was found, so that the nasal bones could only be kept in their position by the aid of the external skin. Even during life 227 larvæ escaped. Similar destructive processes were found in the case communicated by Richardson.[1089] In two cases reported by Schmidt[1090] 300 and 350 larvæ were respectively removed from the nose, and the patients recovered. Wolinz[1091] found his patient had lost consciousness, and that in the pus filling up the entrances to the nose numerous larvæ were moving; recovery followed. In the case communicated by Adler,[1092] more than 150 larvæ escaped from the nose of an old man. Curran[1093] states that people suffering from “peenash” frequently die from meningitis. The cases reported by Pierre[1094] related to the forms of severe myiasis frequently to be observed in Guiana. In a patient who was suffering from typhus (? typhoid), Douglas[1095] found the conjunctival sacs full of larvæ; in two other individuals the nasal cavities were attacked. [1075] [_Chrysomyia macellaria_, p. 587.--F. V. T.] [1076] [_C. macellaria_, Fabricius, the screw-worm fly, is found in tropical America and the West Indies. The genus is restricted to America. The species from India is a Pycnosoma.--F. V. T.] [1077] Riley, _American Naturalist_, 1883, xvii. [1078] Lahory, _Edin. Med. Journ._, 1856. [1079] v. Frantzius, _Virchow’s Archiv_, 1868, xliii. [1080] Lutz, _see_ Joseph, _Deutsch. med. Zeitg._, 1885. [1081] Conil, _Annal. de Science nat. zool._, 1878. [1082] [This fly belongs to the genus Cordylobia, and is peculiar to Africa. _C. anthropophaga_, or the tumbri fly, is, when a larva, a subcutaneous parasite of man and animals.--F. V. T.] [1083] Delasiauve, Gerhardt’s “Handb. d. Kinderkrankh.,” 1878, iii. [1084] Weber, _Mexique Rec. d. Mém. de Méd. milit._, 1867. [1085] Mankiewicz, _Virchow’s Archiv_, 1868, xliv. [1086] Kirschmann, _Wien. med. Wochenschr._, 1881. [1087] Prima, “Thèse de Paris,” 1881. [1088] Britton, Cambridge, Massachusetts, 1883. [1089] Richardson, _Medical Monthly_, 1883. [1090] Schmidt, _Texas Med. Journ._, 1887. [1091] Wolinz, _Wratsch_, 1884. [1092] Adler, _Med. Record_, 1885. [1093] Curran, _Med. Press and Circ._, 1887. [1094] Pierre, “Thèse de Paris,” 1888. [1095] Douglas, _Kansas City Med. Index_, 1890. The case observed by Summa[1096] was that of a man, aged 28, who suffered from nasal obstruction, fœtor, epistaxis and pain in the nose. Out of seven of the cases occurring at Fort Clark, U.S.A., and in its neighbourhood, six ended fatally; in all these cases Kimball[1097] diagnosed ozæna; attracted by the strong odour the flies forced their way into the noses of the patients when asleep and there deposited their ova. In a case reported by Carrière[1098] an abscess of the nasal septum was produced by the larvæ of flies; Chiodi[1099] reports seven cases of myiasis due to _Lucilia macellaria_; among these was a case of rhinitis myiatica, in which a cerebral abscess leading to a fatal termination developed, being produced by the migration of a larva into the brain. Among the three cases of Lesbini[1100] was that of a girl, aged 16, with 250 larvæ in the diseased nasal cavity. Quintano[1101] observed larvæ beneath the eyelids in one case. It is possible that the cases of Cesare[1102] and Calamida[1103] were those of myiasis nasi due to _Lucilia macellaria_. The larvæ are also found in the nasal accessory sinuses, as is seen from the cases reported by De Saulle[1104] (frontal sinus), Delasiauve[1105] (frontal sinus), MacGregor[1106] (antrum of Highmore), and Bordenave[1107] (antrum of Highmore). [1096] Summa, St. Louis, 1889. [1097] Kimball, _New York Med. Journ._, 1893. [1098] Carrière, _Gaz. hebd. de Méd. et de Chir._, 1898, xciv. [1099] Chiodi, _La Argent. Med._, March 1, 1905. [1100] Lesbini, _ibid._ [1101] Quintano, “Cronic oftalm. de Cadiz,” 1878. [1102] Cesare, _Arch. ital. di Otol._, April, 1903. [1103] Calamida, _Giorn. d. R. Accad. de Med. di Torino_, September, 1903. [1104] De Saulle, _Gaz. des Hôp._, Paris, 1857. [1105] Delasiauve, _Gaz. hebd. de Méd._, Paris, 1885. [1106] MacGregor, _Arch. gén. de Med._, No. 1,031. [1107] Bordenave, “Deuxième Mém. présenté à l’Acad. de Chir.,” v, p. 387. If a survey is made of the literature of the cases described of myiasis nasi produced by _Lucilia macellaria_[1108] the following information is forthcoming: In Europe this form of the disease is of very rare occurrence, whilst in America and India[1109] it is frequent. Persons suffering from ozæna are rendered the most liable to danger as the penetrating odour entices the flies in tropical countries with intense frequency, so much so that v. Frantzius does not consider this myiasis as an independent disease, but as a complication of ozæna of frequent occurrence in warm countries. The infection is so far of interest in its nature, in that it only takes place during the day. The fly is on the wing only by day when the sun is shining, and consequently only deposits its eggs at this time. Therefore persons suffering from ozæna are principally exposed to the danger of being pursued by the flies when they succumb to sleep during the mid-day hours in the open or in dwellings that are not closed up. [1108] [And the other species, of course, must be included here.--F. V. T.] [1109] [Concerning Europe and India, _macellaria_ does not occur.--F. V. T.] Headache is the symptom which most troubles the patients. It extends over the whole cranium and persists uninterruptedly, with more or less severe periods. Violent headaches in the frontal and buccal regions are almost always present in this complaint; they are experienced either only on one side or on both simultaneously; sometimes the pain is extended to the lower jaw and region of the neck, following the whole extent of the trigeminal nerve. The inflammation of the nasal mucosa produced by the penetration into it of the larvæ extends right into the frontal sinus and antrum. Simultaneously the patients, at the height of their trouble, suffer from persistent sleeplessness and severe vertigo, so that they reel and cannot walk straight; excessive sneezing always sets in at the commencement. The larvæ immediately spread over the nasal mucosa to seek a place suitable to feed, and irritate the nasal mucous membrane by the tickling sensation they produce. Later the patients frequently sneeze when the maggots move to and fro. One very characteristic symptom consists in the peculiar swelling of the face, which is extended either over the whole or only one half of it, and may alternate with attacks of erysipelas (Brokaw[1110]). [1110] Brokaw, _see_ Seifert, in Heymann’s “Handb.,” p. 595. The discharge from the nose is of special diagnostic value. It consists of a blood-stained serous matter or blood-stained fluid, which is perpetually trickling from one or both nostrils. The larvæ especially choose the anterior portions of the nasal cavity, where they can be seen lying in groups together at the base of the choanæ. The consequence of this is that the soft palate becomes intensely swollen, and this in turn makes swallowing very difficult; speech is impeded, and the voice acquires a nasal intonation. Symptoms of fever become more or less pronounced according to the number of larvæ present, and according to the nature and constitution of the individual. The appetite is in abeyance throughout the whole duration of the illness, and sometimes there is the onset of slight attacks of diarrhœa. If the larvæ are not removed in good time there follows excessive destruction of the interior of the nose and of the turbinals; and the whole nasal framework undergoes disintegration, frequently, too, the velum palati, so that the larvæ come into sight in the oral cavity. Individuals thus severely attacked succumb through exhaustion, symptoms of meningitis (cerebral abscess) or septicæmia (Prima[1111]). Twenty-one out of thirty-eight cases recorded (collected) by Maillard[1112] died. [1111] Prima, “Thèse de Paris,” 1881. [1112] Maillard, “Thèse de Montpellier,” 1870. The method of prophylaxis is self-evident from what has been stated. On bright summer days neither the healthy nor those suffering from diseases of the nose should sleep during the day-time in the open or in public habitations; sufferers from nasal diseases should pay special attention to this. Treatment consists in the removal of the larvæ; this, however, is not always easy. With regard to the methods which have proved to be effectual in the destruction of living larvæ and their expulsion from the nose, strongly smelling and easily diluted fluids come first, such as alcohol, eau-de-Cologne, and ether, which should kill the creatures when injected into the nostrils. The earlier physicians, such as Salzmann,[1113] Honold,[1114] and Henkel,[1115] have seen good results from the use of these methods, whilst Mankiewicz[1116] and Goldstein[1117] obtained no results whatever. Kimball’s[1118] careful investigations have shown that a decoction of bitter herbs recommended by Behrends[1119] (tansy, wormwood) have just as little effect as the tobacco decoction employed by Boerhave[1120] and Kilgour.[1121] The sternutatories employed by the older physicians are entirely neglected. Delasiauve[1122] experienced good results from the inhalation of the smoke of paper cigarettes, which were soaked with a solution of 2·0 pot. arsenic in 30·0 distilled water. Whilst, according to Kimball, balsam of Peru had no effect on the larvæ, Mankiewicz succeeded in removing the larvæ from the nose with the help of that drug. Turpentine steam or mixtures of turpentine employed by Indian physicians have not been very effectual according to Moore,[1123] Kimball and Goldstein. Success has been attained in some cases by the use of insufflations of calomel (Roura,[1124] Cerna,[1125] Schmidt[1126]) or of iodoform (Pascal[1127]). Joseph[1128] recommends concentrated alum solution being sniffed up into the nose as very effectual. Sublimate and carbol solutions do not appear to be very successful (Kimball, Moore, Goldstein), whilst benzine inhalations (Pierre[1129]) have shown better results. Scheppegrell[1130] strongly recommends injections of oil which kill the larvæ, while it is perfectly harmless to the nasal mucosa. Cesare[1131] employed nasal lavages with solutions of salicylate of soda with good results, and Calamida[1132] lavages with physiological saline solution. Bresgen[1133] recommends the nose being cocainized and the larvæ being removed with a pincette. Roorda-Smit[1134] cocainized the nose, then insufflated calomel and plugged the nose with a gauze tampon dusted with calomel. After two hours fifty-six larvæ crawled out along the plug. Continuation of the treatment resulted in a complete cure. [1113] Salzmann, _see_ Tiedemann, Mannheim, 1844. [1114] Honold, _ibid._ [1115] Henkel, _ibid._ [1116] Mankiewicz, _Virchow’s Archiv_, 1868, xliv. [1117] Goldstein, _New York Med. Journ._, 1892. [1118] Kimball, _ibid._, 1893. [1119] Behrends, _see_ Tiedemann. [1120] Boerhave, _ibid._ [1121] Kilgour, _ibid._ [1122] Delasiauve, _loc. cit._ [1123] Moore, _Chicago Med. Times_, 1893. [1124] Roura, _Gaz. di San. milit._, 1884. [1125] Cerna, _New York Med. Journ._, 1893. [1126] Schmidt, _Texas Courier_, 1884. [1127] Pascal, _Arch. d. Méd. milit._, 1895. [1128] Joseph, _Deutsch. med. Zeitg._, 1885. [1129] Pierre, “Thèse de Paris,” 1888. [1130] Scheppegrell, _New York Med. Journ._, 1898. [1131] Cesare, _loc. cit._ [1132] Calamida, _loc. cit._ [1133] Bresgen, Eulenburg’s “Real. Encyclopädie,” third edition. [1134] Roorda-Smit, _Deutsch. med. Wochenschr._, 1906. Injections of chloroform water (Jourdran[1135]) or chloroform inhalations, or injections of pure chloroform into the nose, have proved the most effectual (Goldstein,[1136] Osborn,[1137] Jourdran, Durham,[1138] Jennings,[1139] Kimball,[1140] Mackenzie,[1141] Oatmann,[1142] Zarniko,[1143] Antony,[1144] Folkes[1145]). Camphorated carbolic solutions are very well spoken of: Grayson[1146] states that these kill the larvæ immediately. Some authors have removed the larvæ with forceps (Goldstein[1147]), others with pincettes; thus Brokaw extracted 200 fragments with the forceps, Pascal eighty fragments with the pincettes, and Wolinz[1148] also appears to have removed the larvæ with forceps. [1135] Jourdran, _Arch. de Méd. nav._, 1895. [1136] Goldstein, _New York Med. Journ._, 1892. [1137] Osborn, _Daniel’s Med. Journ._, 1891. [1138] Durham, _Chicago Med. Times_, 1893. [1139] Jennings, _Kansas City Med. Index_, 1890. [1140] Kimball, _New York Med. Journ._, 1893. [1141] Mackenzie, “Diseases of the Nose and Throat.” [1142] Oatmann, _Med. Mirror_, February, 1894. [1143] Zarniko, “Lehrb. d. Krankh. d. Nase.” [1144] Antony, _Bull. Soc. méd. des Hôp. de Paris_, 1903. [1145] Folkes, _New York Med. Record_, 1907. [1146] Grayson, _St. Louis Med. and Surg. Journ._, 1891. [1147] Goldstein, _New York Med. Journ._, 1892. [1148] Wolinz, _Wratsch_, 1884. Greater operative measures than these do not appear to have been undertaken in latter days; yet Morgagni[1149] states that the army surgeon, Cæsar Mogatus, at Bologna, first trephined the frontal sinus and then extracted a “worm” from it. [1149] Morgagni, _see_ Tiedemann. Larvæ of other _Muscidæ_ have come under observation much more rarely (Cheval[1150] [larvæ of _Galleria mellonella_[1151]], Bond,[1152] Dumesnil[1153] [larvæ of _Piophila casei_]). Species of the genus Scolopendra (_Myriapoda_), which all shun the light and seek their food during the night--which consists of animal and vegetable substances--frequently make their way into the nasal cavities of people when asleep. They are found not only in the nose, but in the accessory cavities. In the chapter on the “Parasites of the Nose”[1154] we have collected striking instances, but we have omitted to mention the observation made by Bertrand[1155] (Scolopendra in sinus maxillaris) and that made by Bergmann[1156] (Scolopendra in sinus frontalis). In the same chapter some remarks are made as to the occurrence in the nose of earwigs, caterpillars, scorpions and termites, as well as of animals which have not been identified. [1150] Cheval, _Journ. de Méd. et de Chir._, 1893. [1151] [This is the larva of a moth.--F. V. T.] [1152] Bond, _Int. Zentralbl. f. Laryng._, 1896. [1153] Dumesnil, _see_ Friedreich, “Die Krankh. d. Nase,” 1858. [1154] Seifert, _see_ Heymann’s “Handb.” [1155] Bertrand, _Soc. méd. de Bologne_, 1839. [1156] Bergmann, _Korrespondenzbl. d. deutsch. Ges. f. Psych._, Neuwied, 1859. The larvæ that develop in the auditory meatus penetrate the membrana tympani, destroy the middle ear and may produce meningitis and intracranial suppurations. In one case Vesescu[1157] extracted seven living larvæ from the ear with the aid of a thin pair of pincettes. Köhler[1158] recommends the infusion of drops of ol. terebinth. to destroy the larvæ, Quintano[1159] the insufflation of the following powder: Oxid. hydrarg. rubr., sulfur., āā 1·0 grm., pulv. gi. arab. 8·0 grm.; Lesbini[1160] recommends tincture of iodine. In the case reported by Henneberg[1161] the larvæ were those of _Lucilia cæsar_. [1157] Vesescu, _Riv. stiintelor med._, February, 1906. [1158] Köhler, _Monatsschr. f. Ohrenheilk._, 1885. [1159] Quintano, _see_ Seifert, _loc. cit._ [1160] Lesbini, _La Argent. Med._, 1905. [1161] Henneberg, _Berl. med. Ges._, February 18, 1903. Eye affections due to _Lucilia macellaria_ are very uncommon; the literature relating to the lesions of the eye produced by the larvæ of flies has been collected in Kayser’s[1162] work. In the cases under the observation of Schultz-Zeyden[1163] both the eyes of a female tramp were destroyed, and quantities of larvæ were also found in the nasal fossæ and in the ears. [1162] Kayser, _Klin. Monatsbl. f. Augenheilk._, 1905. [1163] Schultz-Zeyden, _Berl. klin. Wochenschr._, 1906. The Lucilia is found relatively seldom on the cutaneous surface. Henneberg’s[1164] case was that of a neglected girl, aged 20, in whom countless larvæ (_L. cæsar_) were found in a plica polonica; after the plica polonica had been removed the scalp was found to be covered with a large quantity of ulcers which swarmed with larvæ, large and small. The skin of the trunk was also much macerated and covered with larvæ. Death resulted from sepsis; Westenhöffer[1165] remarks on this case that a lesion of the head from which the patient had suffered previously and the perpetual state of intoxication in which she was had probably given rise to the lodgment of the fly larvæ. Whether the communications made by Munk[1166] of maggots in the mouth relate to Lucilia I do not know. Vesescu,[1167] in one case with extensive ulceration and deep fistulæ in the skin, removed 176 larvæ with the pincette. In Roorda-Smit’s[1168] case there were two ulcers in the neck of a girl, aged 17, and larvæ appeared at their base. After dusting with calomel and the application of a bandage the next day fifty-two dead or half-dead larvæ came to light. Recovery took place. Lesbini,[1169] in the case of an old lady, saw numerous larvæ in an ulcer of the leg she was suffering from. Hector’s[1170] case appears to have been one of myiasis cutanea provoked by Lucilia. [1164] Henneberg, _Berl. med. Ges._, February 18, 1903. [1165] Westenhöffer, _Verein f. innere Med._, Berlin, May 7, 1906. [1166] Munk, _Wien. med. Presse_, xxi. [1167] Vesescu, _loc. cit._ [1168] Roorda-Smit, _Deutsch. med. Wochenschr._, 1906. [1169] Lesbini, _loc. cit._ [1170] Hector, _Lancet_, 1902. The first exact observations of myiasis cutanea from _Sarcophaga magnifica_ are due to Wohlfahrt,[1171] in whose honour Portschinsky[1172] named this species of fly _S. wohlfahrti_. Portschinsky ascertained that _S. wohlfahrti_ was not confined to man as its sole host, but that several of our domestic animals, such as cattle, horses, pigs, dogs and geese, were visited. In these animals small wounds serve to entice the flies and to supply them with a suitable site for the deposition of their eggs. The oral armature of the young larvæ renders it easy for them to penetrate not only the mucosa and cutaneous surface but also intact places in the submucous connective tissue. In many localities more than half the herds have proved to be infected by the flies. The fly only frequents open spaces and never enters human dwellings, and is so timid that it approaches man only during sleep; infection, therefore, takes place only out of doors, in summer, in clear, warm weather, and only in such individuals as sleep in the open air. Individuals are most exposed to risk who suffer from catarrhs or inflammations, combined with purulent secretions of the nasal cavity (ozæna), or otorrhœa, or ulcers in any parts of the body accessible to the female fly. [1171] Wohlfahrt, “De vermibus per nares excretis,” Norimbergae, 1770. [1172] Portschinsky, “Norae Soc. entomolog. Rossicae,” 1875. The frequency and intensity of the infection will be in inverse proportion to the advance in civilization of the inhabitants, their idea of cleanliness, their having timely medical aid and the chances of their being rapidly attended to. On that account the majority of cases of myiasis (Sarcophaga) are reported from Russia. The literature of this kind of myiasis nasalis is not very extensive; in addition to Wohlfahrt, Portschinsky and Joseph,[1173] there is a communication by Gerstäcker,[1174] who found fifteen adult larvæ of _S. wohlfahrti_ in the nasal cavity of one man. The larvæ transmitted from Ordruf by Dr. Thomas to Löw,[1175] in Vienna, which were discharged from the nose of a woman, aged 71, suffering from ozæna, were recognized by the well-known dipterologist Braun as belonging to _S. wohlfahrti_. Among the cases reported by Joseph, one only affected the nose; it was that of a peasant girl, aged 11, who had suffered from ozæna; she had travelled on the open road and had there gone to sleep. Severe symptoms set in and death followed under delirium. In making the _post-mortem_ it was found that the interior of the nose was extensively destroyed by larvæ of _S. wohlfahrti_. Powell found Sarcophaga larvæ in two persons who had slept in the open air; the larvæ were killed by injections of chloroform and sublimate. Destruction of the eyes by _S. wohlfahrti_ has only been observed in a few cases; it is reported by Cloquet[1176] that, in the case of a ragman who had lain some time in the fields, both eyes were pierced by larvæ. On the outer skin the larvæ of _S. wohlfahrti_ have been found more than once in inflammatory or festering areas. Freund[1177] demonstrated that from a five year old child, which had suffered for some time from an impetiginous eczema of the skin of the head, from two suppurating abscess cavities which extended to the periosteum, which was already affected, twenty-one living larvæ were taken; rapid healing took place under antiseptic bandaging. [1173] Joseph, _Deutsch. med. Zeitg._, 1885. [1174] Gerstäcker, “Sitzungsberichte d. Ges. f. naturf. Freunde in Berlin,” 1875. [1175] Löw, _Wien. med. Wochenschr._, 1883, xxxi. [1176] Cloquet, _see_ Schultz-Zehden, _loc. cit._ [1177] Freund, _Ges. f. innere Med. in Wien_, December 5, 1901; and _Wien. med. Wochenschr._, 1910, li. The small treatise by Balzer and Schimpff[1178] contains two new observations on myiasis externa; in the one case an ulcer on a man’s foot was full of larvæ, in the other case the head of a woman showed numerous larvæ without the skin of the head being destroyed. Brandt’s[1179] observation is interesting, for he found such larvæ in the gums of a sick person. [1178] Balzer and Schimpff, _Annal. de Derm. et de Syph._, 1902. [1179] Brandt, _Wratsch_, 1888. The impression which one obtains of the active movement of larvæ on wounds is a strange and at the same time uncanny one. One finds that the larvæ to obtain protection against the drying of the surface of the abscess almost incessantly burrow with their heads, first contracting and then expanding the body, which rises and falls, and keeping the tail upwards. Owing to these movements producing irritation, increase of inflammation may ultimately arise, causing erysipelas and cellulitis. The treatment of myiasis nasalis caused by Sarcophaga is the same as in myiasis caused by Lucilia, and in the other places where found it is merely a question of the removal of the larvæ and the subsequent proper treatment of the surface of the abscess. In Northern Nigeria Lelean[1180] found _Auchmeromyia depressa_ to be the cause of myiasis externa.[1181] [1180] Lelean, _Brit. Med. Journ._, 1904. [1181] [Numerous instances of attacks by Auchmeromyia are known and referred to under that genus, pp. 593–4. The species referred to here is not _depressa_, Walker.--F. V. T.] The occurrence of Oestrid larvæ in a human being is very rare, at least up till now myiasis oestrosa has been very seldom observed in man in Europe. Whilst the hosts of the _Muscidæ_ comprise a considerable number of warm-blooded animals, on which the larvæ develop, each species of the _Oestridæ_ appears, on the other hand, to have a definite host or some definite hosts of the class Mammalia. No species of Oestrid is peculiar to man. Although in America, as well as in Europe, _Oestrus hominis_ was spoken of up to the middle of the last century, no such species exists. But in both hemispheres, in America much more often than in Europe, Oestrid larvæ have been found in man. In Florida, Mexico, New Granada, Argentina, Brazil, Costa Rica and other districts, and especially where large herds of cattle are kept, myiasis oestrosa has been observed in shepherds, huntsmen and amongst the rural population. The larvæ of _Hypoderma bovis_, according to the observations of Goudot,[1182] occur as a parasite in man. Poilroux[1183] found larvæ of cavicolous _Oestridæ_ in the nose of a man, aged 55. Amongst the species of warble flies, whose larvæ are parasites in domestic animals and game in Europe, reliable observers have found larvæ of two kinds, _Hypoderma bovis_ and _Hypoderma diana_, also in man.[1184] [1182] Goudot, _Annal. d. Sci. nat._, 1845. [1183] Poilroux, _Journ de Méd., Chir._, etc., 1809. [1184] [_Hypoderma linearis_ is frequently confused with _H. bovis_.--F. V. T.] The larvæ of _H. bovis_ have very seldom been observed in the nose. The case quoted by Kirschmann,[1185] which was that of a peasant woman, aged 50, who was suffering from ozæna, and in which violent attacks of sneezing, epistaxis, pain in the forehead, and swelling of the face were observed, is, according to Löw[1186] and Joseph,[1187] not an Oestrid; Muscid larvæ were evidently the cause. By the injection of diluted iron chloride solution seventy-nine larvæ were removed from the nose. In the case reported by Razoux[1188] the species of larva is not definitely known--at least, v. Frantzius[1189] did not consider them Oestrid larvæ. Joseph does not definitely say that Oestrid larvæ were the cause of a case which he quotes. He was sent a number of uninjured larvæ of _Oestrus ovis_ ready to pupate, which were said to have been expelled, during violent sneezing, from the nose of a peasant woman who had suffered for six months from continuous frontal headache and chronic nasal catarrh. [1185] Kirschmann, _Wien. med. Wochenschr._, 1881. [1186] Löw, _Wien. med. Wochenschr._, 1882. [1187] Joseph, _Deutsch. med. Zeitg._, 1885. [1188] Razoux, _Journ. de Méd., Chir._, etc., 1758. [1189] v. Frantzius, _Virchow’s Archiv_, 1868, xliii. The Oestrides prefer to use the surfaces of wounds on the skin of man to lay their eggs, which develop into larvæ; but they often use their ovipositors[1190] to make a fresh wound. In this case there arise in the skin, and particularly in the subcutaneous connective tissue of the neck, in the region of the shoulder, as well as in other parts of the body painful, furuncle-like inflammations which are known under the name of gad-fly boils. These boils may become the size of pigeons’ eggs; if several are together, they appear to form a connected tumour. Each tumour is elastic and somewhat movable, and has an orifice through which the larva breathes and discharges its excreta. At times these turn to festers and gangrenous disintegrations, which may even cause the loss of a limb. Wilms[1191] had the opportunity a few years ago of observing a case of myiasis dermatosa oestrosa in Leipzig. The fistula which led to the larva was slit open and the larva extracted. As a notable characteristic of myiasis oestrosa Joseph states that the larvæ grow very slowly. The flight time of the _Oestridæ_ is the hot summer months. [1190] [The Oestrides appear to lay their ova on the hair of animals. They do not puncture the skin.--F. V. T.] [1191] Wilms, _Deutsch. med. Wochenschr._, 1897. Adams[1192] observed on the Isthmus of Panama a number of cases of a skin disease which is caused by the larvæ of _Dermatobia noxialis_ (_Gusano-peludo-Muche_). The larvæ penetrate not only the skin but also the mucous membrane of the pharynx and larynx, and from there proceed through the tissue to the subcutaneous cellular tissue. The infection seems to result from bathing. [1192] Adams, _Journ. Amer. Med. Assoc._, 1904. The study of “thimni,” a human myiasis caused by _Oestrus ovis_, by Ed. and Et. Sergent,[1193] deals more with the zoology and with the geographical distribution of this insect in North Africa than with the clinical appearances of myiasis. [This paper deals with matters of great interest, with important facts.--F. V. T.] [1193] Ed. and Et. Sergent, _Annal. de l’Inst. Pasteur_, 1907. The treatment consists in the removal of the larvæ (from the nose); in Brazil it is the custom to drop tobacco juice into the boil in order to kill the larvæ (Strauch[1194]). [1194] Strauch, _Journ. of Cut. Dis._, 1906. One is only justified in speaking of myiasis intestinalis when there is no doubt that living fly maggots or flies themselves can be proved to have been found in the fresh contents of the stomach or intestine (Schlesinger and Weichselbaum[1195]). In the discussion of myiasis intestinalis we give the evidence of Schlesinger and Weichselbaum, as well as that of Wirsing,[1196] to which must be added a number of other investigations. [1195] Schlesinger and Weichselbaum, _Wien. klin. Wochenschr._, 1902, i. [1196] Wirsing, _Zeitschr. f. klin. Med._, 1906, lx. In a great number of acute cases apparently only the stomach was affected, there being no signs in the intestine. In these cases sudden illness is noticed, colic, sometimes unbearable pains in the region of the stomach, pyrosis, vomiting or continuous intense inclination to vomit, occasionally even with the mixture of blood. Frequently a general feeling of malaise, twinges of pain in the muscles, and attacks of giddiness were notified, very rarely fever. Generally all the symptoms disappeared in a short time when the larvæ had been removed by an act of vomiting or by washing out the stomach. It is well to note that in the history of many cases the pains preceding the expulsion of the larvæ are stated to be extremely violent. Acute myiasis of the intestinal canal frequently runs a course without special symptoms and is only an accidental condition; one has, however, in such cases to guard against errors. The fæces may be deposited in vessels or places where fly larvæ are in great numbers, or a subsequent infection of the fæces with the eggs or larvæ of flies may have taken place. Only when the inspection of the excrement immediately following defæcation proves the presence of living larvæ, and when there were certainly no fly larvæ in the vessel previously, can one speak of the passing of fly larvæ from the intestine. More frequent than the cases showing no special symptoms are those with pronounced disturbances in the intestinal passage, obstruction or diarrhœa (also constipation and diarrhœa alternately), violent and sometimes agonizing abdominal pains (Pottiez[1197]), which preceded the evacuation of the larvæ and subsided after their removal. General symptoms, like weakness, languor, transitory vague pains, loss of appetite, sickness, rarely fever, giddiness, attacks of faintness, epileptic attacks (Krause[1198]) are observed. In a few cases blood and pus have been noticed in the evacuation of the bowels. [1197] Pottiez, _Bull. de l’Acad. royale de Méd. de Belgique_, xv. [1198] Krause, _Deutsch. med. Wochenschr._, 1886, xvii. In the cases of chronic myiasis of the intestine the aspect of the disease is dominated by the complex symptom of colitis mucosa. The following features are noticeable, namely, the intermittent passing of blood, the influence over the expulsion of the larvæ of mechanical procedure (massaging of the abdomen), the duration of the process for several years, the sometimes enormous number of insects contained in the dejecta. Another clinically important factor is the passing of the larvæ in batches. While for some time no larvæ may appear in the stools, they may suddenly be ejected in great numbers, either because the conditions of feeding are not suitable, or because medicaments remove them from the intestine. The hæmorrhage is ascribed by Schlesinger and Weichselbaum directly to lesions of the mucous membrane caused by the larvæ; in the case reported by these writers there were found shreds of tissue as well as pus in the stool. The pains occurring spontaneously in the abdomen are at times influenced by position and attitude of the body, often they were more violent after rest and after evacuation of the bowels; often they were continuous, but in that case less intense; pressure on the abdomen is generally little felt. The condition of the blood was in two cases (Pasquale[1199] and Schlesinger and Weichselbaum) a marked chlorotic one. The state of nutrition seems almost always to suffer with prolongation of the disease, but in Peiper’s[1200] cases this was not so. The condition of the appetite was in some instances good, in others very bad. A frequent symptom is headache of a migraine-like character and neuralgic pains in different parts. [1199] Pasquale, _Centralbl. f. Bakt._, 1891. [1200] Peiper, “Fliegenlarv. als gelegentl. Parasiten d. Menschen,” Berlin, 1900. Schlesinger and Weichselbaum’s case shows that there are forms of myiasis intestinalis which, after prolonged sickness, lead to death, and that in consequence of the formation of intestinal abscesses stricture of the intestine may arise from the subsequent formation of a scar. The question of the mode of infection is interesting; in this mouth, nose and anus must be considered. The most frequent way is certainly by means of food on which flies have laid their eggs, or which is permeated with young maggots. This may be raw (especially grated) meat, cheese, fruit, salad, milk, cabbage, cold farinaceous foods, raspberries. When the stomach is affected, when the gastric juice has lost acidity and power of digestion, the larvæ will be able to stay and develop more easily. According to Csokor,[1201] if the eggs get into the gastro-intestinal canal of man with the food, the delicate stages of the young larvæ would certainly not survive the action of the gastric juice. Salzmann[1202] assumed that the invasion occasionally occurred through the rectum, the larvæ creeping into the anus while the person is asleep. Wirsing accepts this method of infection for two of his cases, where it was a question of the infection of an infant. Salzmann[1202] reports a case where the maggots of _Anthomyia_[1203] _scalaris_ were passed in great numbers from the urethra of an old man. The patient had been catheterized on account of urethral stricture and was probably infected with eggs or larvæ at the same time. [1201] Csokor, _Wien. klin. Wochenschr._, 1901, p. 129. [1202] Salzmann, _Württemberg. med. Korrespondenzbl._ 1883, liii. [1203] [This is presumably _Homalomyia_ (_Fannia_) _scalaris_.--F. V. T.] The diagnosis of the affection is easy and sure, if living larvæ are found in the contents of the stomach or in the stools, and if contamination is out of the question. The number of different species of flies whose larvæ are found in myiasis intestinalis is considerable. The larvæ of species of Anthomyia (_A. canicularis_,[1204] _A. scalaris_, _etc._), of _Sarcophaga carnaria_ and _S. magnifica_ and of _Musca vomitoria_[1205] are especially observed. [1204] [This fly, common in houses, is known as _Homalomyia canicularis_, and the next belongs to the same genus.--F. V. T.] [1205] [This fly belongs to the genus _Calliphora_, not _Musca_.--F. V. T.] The prognosis is certainly generally favourable, but must be made with some reserve in chronic cases, in view of the observations of Schlesinger and Weichselbaum (intestinal stenosis). The treatment must aim at removing the larvæ as soon as possible from the digestive canal. In cases of myiasis of the stomach, a thorough washing out of the stomach (Joseph,[1206] Staniek[1207]) is to be preferred to emetics used with success in individual instances; perhaps it would be advisable to add menthol or thymol to the mixture. [1206] Joseph, _Deutsch. med. Zeitg._, 1885 and 1887. [1207] Staniek, _see_ Schlesinger and Weichselbaum, p. 47. In myiasis of the intestine internal remedies and local treatment of the intestine must be considered. So far santonin seems to have proved to be the best remedy. In some cases extract. filicis maris, calomel, semina cucurbitæ, naphthalene 0·1 to 0·5 (Peiper[1208]), infus. of Persian insect powder (5 in 200), mineral waters, Carlsbad water, seem to have had good results. [1208] Peiper, “Fliegenlarv. als gelegentl. Parasiten d. Menschen,” Berlin, 1900. For irrigation of the rectum, weak solutions of argentum nitricum, tannin, thymol, gelatine, ol. ricini, naphthalene may be used. Wirsing administered an aperient (Rurella compound liquorice powder) and a soap enema after the passing of the first larvæ. The principal thing is the prophylaxis, which must include the careful protection of articles of food, on which flies may lay their eggs (protection by glass dishes, tulle or fine wire nets). Fruit should not be eaten before being washed or rubbed with a cloth. *Gastricolous Oestridæ* (Creeping Disease). Syn.: _Creeping eruption_; _Larva migrans_; _Hautmaulwurf_; _Dermatomyiasis linearis migrans oestrosa_; _Hyponomoderma_; _Dermatitis linearis migrans_; _Linea migrans_; _Epidermiditis linearis migrans Wolossatik_; _Kriechkrankheit_; _Hautkratzschorf_; _Myiase hypodermique_. Under the name “creeping disease,” R. J. Lee[1209] has recorded a peculiar affection of the skin in a three year old girl, which appeared first in the form of pale red, thread-like irregular protuberances, which seemed partly to become entwined on the right malleolus and had spread without causing special disturbances to the abdomen. Dickinson, Fox and Duckworth[1210] reported, in connection with this, that they observed a growth of this red line of about 1 in. per diem. Since then a number of similar cases have been reported which, without doubt, were cases of larvæ creeping under the skin. Crocker[1211] saw such a case in a two year old girl, the progress of the red line varying in one night between 4 and 7-1/2 in. In Europe the first case was observed in Vienna, by v. Neumann and Rille,[1212] also in a two year old girl. [1209] R. J. Lee, _Journ. Clin. Soc. Lond._, November 27, 1874. [1210] Dickinson, Fox and Duckworth, _ibid._, 1875. [1211] Crocker, “Diseases of the Skin,” 1893; “Atlas of the Diseases of the Skin.” [1212] v. Neumann and Rille, _Wien. klin. Wochenschr._, 1895; _Dermatologenkongr._, Graz, 1895. v. Samson-Himmelstjerna,[1213] Sokoloff,[1214] Rawnitzky[1215] found larvæ at the end of the tract, which had been recorded as larvæ of Gastrophilus by Cholodowsky.[1216] According to Blanchard (_Arch. f. Par._, 1901) the larvæ were those of _Hypoderma bovis_. [1213] v. Samson-Himmelstjerna, _Wratsch_, 1895; _Arch. f. Derm. u. Syph._, 1897. [1214] Sokoloff, _Wratsch_, 1896. [1215] Rawnitzky, _Derm. Zeitschr._, v, p. 704. [1216] Cholodowsky, _Wratsch_, 1896. How these larvæ get into the skin has not yet been definitely ascertained; v. Samson is of the opinion that they usually obtain access to man as larvæ, Stelwagon[1217] believes that the infection generally occurs in a seaside watering place; a patient of Ehrmann’s[1218] fell ill when he returned from the manœuvres, where he had lain for some time on the ground. Here and there it is reported that the eruption was preceded for a longer or shorter time by lesions of the skin (incised wounds, furuncles, slight excoriations, v. Harlingen[1219]). [1217] Stelwagon, _Journ. Cut. Dis._, xxii, 8. [1218] Ehrmann, _Wien. derm. Ges._, November 17, 1897. [1219] v. Harlingen, _Amer. Journ. of Med. Sci._, 1902. Twice it has been suggested that perhaps the parasites might come from vineyard snails (Crocker, Lenglet and Delaunay[1220]), and it is pointed out by v. Samson that in Russia the infection of peasants who work in the fields was specially frequent. It is noticeable how frequently the affection begins on uncovered parts of the body (face, hands, arms); but that fact, on the whole, is not in conflict with the statement (Kengsep[1221]) that the disease makes its first appearance over the nates, because children often sit on the ground and play with that part of their body uncovered. A case observed by us was that of an elderly lady who did not do this and was properly clothed, yet showed the typical lines of creeping disease on the nates, and asserted again and again that she had the feeling as if a worm were creeping under her skin. [1220] Lenglet and Delaunay, _Annal. de Derm. et de Syph._, 1904. [1221] Kengsep, _Derm. Centralbl._, 1906, vii. The disease occurs in children as well as adults, so that age, sex and calling offer no determining point etiologically. The clinical symptoms of the disease consist in the sudden appearance of itching and burning; if the cause is looked for one perceives a red line, raised but little above the surface of the skin, with irregular curves, never branched, but often entwined, broadening more or less rapidly at one end (1 to 15 cm. in twenty-four hours). The larva can be seen sometimes with a lens under pressure of the skin as a dark spot; formations of pus, such as other larvæ produce, are not noticed; now and again there is a formation of little vesicles (Hamburger,[1222] v. Harlingen,[1223] Bruno,[1224] Ehrmann,[1225] Brodier and Fouquet,[1226] Rawnitzky[1227]). It may happen that the parasite burrows through a small region of the skin with many close curves for some time; on the other hand, observations exist where it covered large tracts in a short time. The itching and smarting cease in the place left by the larva, so that the patients even in the shortest tract can point out at which end the larva is, even if they have not watched the lengthening of the tract. Very rarely the larva invades the mucous membrane of the mouth, the nose, and the conjunctiva, proceeding from thence to the external cutaneous area. [1222] Hamburger, _Journ. of Cut. Dis._, 1904. [1223] v. Harlingen, _loc. cit._ [1224] Bruno, v. Rille and Riecke, “Handb. d. Hautkrankh. v. Mraček.” [1225] Ehrmann, _loc. cit._ [1226] Brodier and Fouquet, _Bull. de la Soc. franç. d. Derm._, 1904. [1227] Rawnitzky, _loc. cit._ The localization of the affection is very varied; the primary seat has been observed on the glutei muscles (Lee, Kengsep, Morris,[1228] Rille, Seifert) and their surroundings (Stelwagon, Hamburger, Bruno), on the lower extremities (Stelwagon, Lenglet and Delaunay, Hutchins, Moorhead, Lee, Crocker, Schmid,[1229] v. Harlingen), on the upper extremities (Samson, Meade and Freeman, Hutchins, Sokoloff, v. Harlingen, Brodier and Fouquet, Shelmire,[1230] Stelwagon), on the face (Sokoloff, Moorhead, Kumberg,[1231] Rawnitzky, Crocker, Boas[1232]), on the neck (Sokoloff), and on the body (Ehrmann, Brodier and Fouquet, Kaposi,[1233] Topsent[1234]). [1228] Morris, _Brit. Journ. Derm._, 1896. [1229] Schmid, _Verein der Aerzte in Steiermark_, February 12, 1900. [1230] Shelmire, _Journ. Cut. Dis._, 1905. [1231] Kumberg, _St. Petersb. med. Wochenschr._, 1898. [1232] Boas, _Monatsh. f. prakt. Derm._, 1907, xliv. [1233] Kaposi, _Wien. klin. Wochenschr._, 1898. [1234] Topsent, _Arch. de Par._, 1901. The duration of the affection varies very much; it varies between a few hours and some years[1235]; several times a spontaneous recovery has been reported. [1235] [This is extremely unlikely, as the bots of Hypoderma only live for nine or ten months at the most!--F. V. T.] The diagnosis of the disease is not at all difficult owing to its peculiar appearance. The treatment can only consist in the removal or killing of the larvæ, since one cannot rely on spontaneous recovery, even if it has occurred in some cases. If one should succeed in locating the larva as a black spot at the end of the tract, its removal by means of a needle is the simplest method (Quortrup and Boas[1236]). In some instances a cure has been successfully accomplished by excision of the active end of the tract (v. Neumann and Rille, Schmid). In opposition to this method, which not all patients will allow, the method practised by Arab women (Rille and Riecke[1237]) of killing the worm with red hot needles is quite rational. Shelmire[1238] used the electrolytic needle for the destruction of the maggots, Stelwagon[1239] made use of cataphoresis, by means of which he applied a sublimate solution, afterwards cauterizing with a drop of nitric acid, as excision was refused. Crocker[1240] and v. Harlingen[1241] injected small quantities of carbolic acid; Moorhead[1242] by a single freezing of the skin with ethyl chloride, attained a definite cessation of the attack at the active end. Hutchins[1243] in one case made use of hypodermic injection of a few drops of solution of cocaine and afterwards of 1 to 2 drops of chloroform; in a second case of repeated applications of tincture of iodide, as Lenglet and Delaunay[1244] did. v. Harlingen[1245] allayed the affection in his first case by rubbing in sapo viridis and tar, in Kensep’s[1246] case the cure seems to have been accomplished by an ointment containing resorcin, in Meade and Freeman’s[1247] case by a 20 per cent. ichthyol paste. In our case we made exclusive use of Lassar’s paste; within four weeks a cure resulted, probably spontaneously, since one cannot ascribe any essential effect to this paste. [1236] Quortrup and Boas, _Hospitalstid._, 1907. [1237] Rille and Riecke, “Handb. d. Hautkrankh.,” v. Mraček, 1907, iv. [1238] Shelmire, _loc. cit._ [1239] Stelwagon, _loc. cit._ [1240] Crocker, _loc. cit._ [1241] v. Harlingen, _loc. cit._ [1242] Moorhead, _Texas Med. News_, 1906. [1243] Hutchins, _Journ. Cut. Dis._, 1906. [1244] Lenglet and Delaunay, _loc. cit._ [1245] v. Harlingen, _loc. cit._ [1246] Kensep, _loc. cit._ [1247] Meade and Freeman, _Brit. Journ. Derm._, October, 1906. APPENDIX ON PROTOZOOLOGY, Comprising Notes on Recent Researches, Formulæ of some Culture Media, and Brief Notes on General Protozoological Technique. BY H. B. FANTHAM, M.A., D.Sc. I.--NOTES ON RECENT RESEARCHES. Since the foregoing section on Protozoology was sent to press, certain interesting observations and results have been published. Brief notes on such, and some references thereto, are now added. It is necessary, however, to remark that sometimes it is impossible to give a precise or rigid definition to a genus of Protozoa, owing to differences of opinion, to differences regarding nomenclature or to incompleteness of knowledge. Such a lack of definition, while inconvenient for the time being, is not unhopeful, as it directs attention to the necessity for further work, which is inevitable in such a relatively new and wide subject as protozoology. Thus, it may be noted in illustration that Minchin, in 1912, in his text-book regarding the genus _Entamœba_ writes: “The entozoic amœbæ are commonly placed in a distinct genus, _Entamœba_, distinguished from the free-living forms by little, however, except their habitat and the general (but not invariable) absence of a contractile vacuole.” *Differences between Entamœba histolytica and E. coli.*--In continuation of the remarks on pp. 34 and 40, it may be added that Lugol’s solution (iodine in aqueous potassium iodide solution) in fresh specimens shows by brownish staining the presence of glycogen in the vacuoles of _Entamœba coli_. Such a reaction is rarely or never given by _E. histolytica_. *Phagedænic Amœbæ.*--Carini and others record cases in which the skin around an operation wound in connection with liver abscess became gangrenous. Amœbæ, possibly _Entamœba histolytica_, were found therein and may have been responsible for the gangreno-phagedænic action. *Endamœba gingivalis* (_see_ pp. 43, 44).--Smith and Barrett,[1248] after analysing the early literature, state (June, 1915) that _Endamœba gingivalis_, Gros, 1849, is the correct name for the following organisms: _E. buccalis_, Prowazek, 1904 (see p. 43); _Amœba gingivalis_, Gros, 1849; _Amœba buccalis_, Steinberg, 1862, and _Amœba dentalis_, Grassi, 1879. They conclude that _E. gingivalis_ is the causal agent of pyorrhœa alveolaris, and that this disease responds to treatment with emetine. [1248] _Journ. of Parasitol._, i, p. 159. *Entamœba kartulisi* (see p. 44), synonym _E. maxillaris_, Kartulis, is considered to be _E. gingivalis_. Smith and Barrett adopt the generic name _Endamœba_, Leidy, 1879 (_see_ footnote on p. 31, also p. 34). Leidy worked on _Endamœba blattæ_. *Craigia and Craigiasis* (_see_ p. 45).--Barlow[1249] (May, 1915) found _Craigia_ (_Paramœba_) _hominis_ in cases of chronic diarrhœa and mild dysentery in Honduras. He also described a new species of _Craigia_ under the name of _C. migrans_. Fifty-six cases were studied, five of which were due to _Craigia hominis_, the remainder to _C. migrans_. In _C. migrans_, each flagellate, on attaining full development, becomes an amœba without dividing. Each amœba encysts and produces a number of flagellates which are somewhat like cercomonads. On the other hand, in _C. hominis_ the flagellate form produces, by longitudinal fission, several generations of flagellates before entering upon the amœbic stage. The cysts of _C. migrans_ contain fewer “swarmers” (flagellulæ) than those of _C. hominis_, but the “swarmers” are somewhat larger, namely, 5 µ instead of 3 µ in diameter. Further, there is no accessory nuclear body in _C. migrans_, but its flagellum stains more deeply than that of _C. hominis_ and has a peculiar banded appearance. [1249] _Amer. Journ. Trop. Dis. and Prevent. Med._, ii, p. 680. *Human Trichomoniasis* (_see_ pp. 52–56).--Lynch[1250] (April and May, 1915), working in Charleston, seems to favour the view that the trichomonads found in the vagina, urethra, mouth, lungs and alimentary tract are one and the same organism, and that these flagellates may further excite already existing inflammatory conditions. He gives detailed histories of cases of (_a_) infection of the vagina and gums, and (_b_) intestinal infection manifested as intermittent attacks of diarrhœa. The flagellates were found in catarrhal vaginal discharge, in blood-stained scrapings from the gums (together with _Endamœba buccalis_), and in stools after a purge of magnesium sulphate. The parasites were tetratrichomonads (_see_ footnote, p. 53), that is, each possessed four flagella anteriorly as well as an undulating membrane. Lynch successfully infected rabbits from the cases and from cultures of the parasite. Encysted trichomonads were seen in a patient’s stools, in rabbits infected therefrom and in cultures. The culture medium used was bouillon acidified with about 0·05 per cent. acetic acid and the cultures were maintained at 30° C. [1250] _Ibid._, p. 627; _New York Med. Journ._, May 1, 1915, ci, p. 886. Trichomonads occur in the digestive tracts, for example, the cæca of rats and mice (fig. 422). In man allied flagellates can occur in similar situations, as well as in other parts of the intestine. [Illustration: FIG. 422.--_Trichomonas_ from cæcum and gut of rat: _n_, nucleus; _bl_, blepharoplast; _fl_, flagella; _ax_, axostyle; _m_, undulating membrane; _b_, line of attachment of undulating membrane to the body. × 2,000 approx. (Original.)] Other trichomonad-like organisms have been recently described from the fæces of man, more particularly from cases of chronic dysentery in the tropics. Derrieu and Raynaud[1251] (July, 1914), working in Algeria, found a flagellate possessing five free flagella anteriorly and an undulating membrane apparently lateral. They named the parasite _Hexamastix ardin-delteili_, but the generic name _Hexamastix_ is pre-occupied. Chatterjee[1252] (January, 1915), working in India, found probably the same flagellate and called it _Pentatrichomonas bengalensis_. [1251] _Bull. Soc. Path. Exot._, vii, p. 571. [1252] _Ind. Med. Gaz._, l, p. 5. *Chilomastix* (*Tetramitus*) *mesnili* (_see_ p. 57).--Alexeieff[1253] (1914) now places the parasite originally called _Macrostoma mesnili_, by Wenyon (1910), in the genus _Chilomastix_, Alexeieff. The differential characters of the genera _Tetramitus_ and _Chilomastix_ are not especially well marked. According to Alexeieff, _Tetramitus_ is characterized by four unequal flagella (which he figures anteriorly), a ventral cytostome in the form of a linear cleft and a pulsatile vacuole in front of the anterior nucleus. _Chilomastix_, according to the same author, has three forwardly directed flagella and a fourth backwardly directed one in the cytostome, which is well developed (fig. 423). Some authors consider that the fourth flagellum forms the edge of an undulating membrane in the cytostome. [1253] _Zool. Anzeiger_, xliv, pp. 203, 206; and _ibid._, xxxix, p. 678. Diagrams of _Chilomastix mesnili_ are given in fig. 423. [Illustration: FIG. 423.--_Chilomastix_ (_Tetramitus_) _mesnili_. _a_, _b_, _c_, flagellate forms; _d_, rounded or encysted form. × 2,500. (Original.)] *Giardia* (*Lamblia*) *intestinalis* (_see_ p. 57).--Alexeieff[1254] (1914) considers that _Lamblia intestinalis_, Lambl, should be placed in the genus _Giardia_, Kunstler, 1882. Bipartition occurs in the encysted state. The axostyles persist in the quadrinucleate cyst. [1254] _Zool. Anzeiger_, xliv, p. 210. *Cercomonas hominis* (_see_ p. 61).--This parasite is considered by some authors to be of a doubtful nature, as it is thought to have been mistaken for deformed or incompletely observed _Trichomonas_ or _Chilomastix_ or even _Lamblia_. Wenyon[1255] (1910) described _Cercomonas longicauda_ from cultures of human fæces. It is considered that the genus is very confused, and the author points out that the tail flagellum has been overlooked. He considers that the genus _Cercomonas_ should include flagellates with an anterior blunt end from which arises a single long flagellum, and a posterior tapering end also with a flagellum, which can be traced over the surface of the body towards the insertion of the anterior flagellum. [1255] _Quart. Journ. Micros. Sci._, lv, p. 241. Another species, _Cercomonas parva_, has been found in cultures of human fæces by Hartmann and Chagas[1256] (1910). It has a somewhat different structure. [1256] _Mem. Inst. Oswaldo Cruz_, ii, p. 67. Further researches are necessary on the organisms variously referred to the genus _Cercomonas_. *Transmissive Phase of Trypanosomes in Vertebrates.*--In addition to the general remarks on the morphology of trypanosomes set forth on pp. 70 to 72, it may be noted that Woodcock[1257] (November, 1914) states that, in certain cases, there is a definite transmissive phase of a trypanosome in its vertebrate host. He quotes the work of Minchin and himself on _T. noctuæ_ of the little owl, in which the transmissive form is spindle-shaped and occurs in the bird’s peripheral blood during the early summer months (_see_ p. 69). A similar phase occurs in _T. fringillarum_, and Robertson[1258] has found that the short, stumpy form of _T. gambiense_ is its transmissive phase in vertebrates. [1257] _Arch. f. Protistenk._, xxxv, p. 197. [1258] _Proc. Roy. Soc._, B, lxxxv, p. 527. *Trypanosoma lewisi* (_see_ p. 88).--Brown (1914–15) has published some interesting results on the potential pathogenicity of _T. lewisi._ *Blepharoplastless Trypanosomes* (_see_ p. 101).--Laveran[1259] (April, 1915) suggested a practical use of strains of blepharoplastless trypanosomes produced by the action of drugs. He finds that tryposafrol will also produce such strains, and remarks on blepharoplastless strains of _T. evansi_ and _T. brucei_, which in the former case can undergo 450 passages without reversion, and in the latter 273 passages. He states that if it is desired to inoculate surra or nagana to Capridæ or Bovidæ in order to produce immunity, use should be made of the blepharoplastless races of the respective trypanosomes, which races are a little less virulent than the corresponding normal ones. Also, the immunity which follows from an infection due to blepharoplastless _T. evansi_ or _T. brucei_ is only a little less complete than that following infections from either of the respective normal strains. [1259] _C. R. Acad. Sci._, clx, p. 543. *The Experimental Introduction of certain Insect Flagellates into various Vertebrates, and its bearing on the Evolution of Leishmaniasis.*--In continuation of the remarks on pp. 103, 104, and 112, further researches have been conducted on the introduction into vertebrates of flagellates normally parasitic in insects. The vertebrates became infected by inoculation with the flagellates or by being fed on insects containing the protozoa. Fantham and Porter[1260] (June, 1915) published the following results. Flagellates from sanguivorous and non-sanguivorous insects were used, and cold-blooded as well as warm-blooded vertebrates as hosts. The introduced protozoa were pathogenic to the mammals, but not markedly so to the cold-blooded vertebrates. _Herpetomonas jaculum_, _H. stratiomyiæ_, _H. pediculi_, and _Crithidia gerridis_ (parasitic in certain waterbugs) proved pathogenic to mice. A puppy was infected by way of the digestive tract with _H. ctenocephali_. Frogs became infected with _H. jaculum_ and with _C. gerridis_, toads and grass snakes with _H. jaculum_, lizards with _C. gerridis_, and sticklebacks with _H. jaculum_. Second and third passages of some of the parasites were obtained. The protozoa, whether _Herpetomonas_ or _Crithidia_, were present in the vertebrate hosts in either the non-flagellate or the flagellate form, or usually both. They were more abundant in the internal organs of the hosts, more particularly in the liver, spleen and bone-marrow. In all experiments in which _C. gerridis_ was used the parasite invariably retained the crithidial facies in the vertebrate host. No transition to a trypanosome was ever seen. Infections in adult animals were not so heavy as in the young ones, and the parasites were more virulent in young hosts, as is the case with Mediterranean kala-azar in children. [1260] _Proc. Camb. Philosoph. Soc._, xviii, p. 137; and _Annals Trop. Med. and Parasitol._, ix, p. 335. The mode of infection of the vertebrate in Nature seems to be contaminative, either by its food or through an already existing abrasion or puncture on the surface of its body. Cases in which the flagellate-infected insects have been allowed to suck the blood of vertebrates have proved negative up to the present. In areas where leishmaniases are endemic, an examination should be made of all insects and other invertebrates likely to come into contact with men or dogs, or rats and mice (see below), in order to ascertain if these invertebrates harbour herpetomonads. Preventive measures should be directed against such invertebrates, especially arthropods. Further, it is likely that certain vertebrates, such as reptiles and amphibia (especially those that are insectivorous), may serve as reservoirs of leishmaniases, or, as they should preferably be termed, herpetomoniases. From such reservoirs the herpetomonads may reach man by the agency of ectoparasites or flies, especially such as are sanguivorous. That vertebrates in Nature can harbour herpetomonads in their blood has been shown by the work of Dutton and Todd (1903) on the herpetomonads of Gambian mice, while the recently published investigations of Fantham and Porter[1261] (June, 1915) on natural herpetomonads in the blood of mice in England have shown that these rodents may be a natural reservoir of herpetomoniasis. The origin of the infection of mice is to be sought in a flagellate of an ectoparasite of the mouse, very probably _Herpetomonas pattoni_ parasitic in various fleas, which protozoön can adapt itself to life in the blood of mice. Herpetomonads were also found naturally in the blood of birds by Sergent (1907). Recently, Fantham and Porter have successfully infected birds with herpetomonads experimentally. [1261] _Parasitology_, viii, p. 128. The significance of insect flagellates in relation to the evolution of disease has recently been set forth by Fantham[1262] (June, 1915). The deductions to be made from the occurrence of a herpetomonad stage in _Leishmania_, especially in _L. tropica_, in man himself, and of flagellate stages of the so-called _Histoplasma capsulatum_ in man are fully discussed and correlated. It is pointed out that flagellosis of plants (see p. 104) may possibly be connected with leishmaniasis. The evolution of _Leishmania_ from flagellates of invertebrates is thus traced and the way again indicated for preventive measures against leishmaniasis, as first set forth by Dodds Price and Rogers. [1262] _Annals Trop. Med. and Parasitol._, ix, p. 335. Franchini and Mantovani (March, 1915) have successfully infected rats and mice by inoculation or by feeding with _Herpetomonas muscæ domesticæ_ obtained from flies and from cultures. It is of great interest to note that the recent observations of Ed. and Et. Sergent, Lemaire and Senevet[1263] (1914) have demonstrated the presence of a herpetomonad flagellate in cultures of the blood and organs of geckos obtained from areas in Algeria in which Oriental sore, due to _L. tropica_, is prevalent. _Phlebotomus_ flies, which may harbour a natural herpetomonad, feed on the geckos and on men. Hence animals like geckos may possibly act as reservoirs of leishmaniasis. Lindsay[1264] (1914) writes that the parasite of dermo-mucosal leishmaniasis in Paraguay is believed by native sufferers to be conserved in rattlesnakes, and spread by ticks or flies (_Simulium_) feeding on the reptiles and transferring the parasite to man. [1263] _Bull. Soc. Path. Exot._, vii, p. 577. [1264] _Trans. Soc. Trop. Med. and Hyg._, vii, p. 259. *The Transmission of Spirochæta duttoni* (_see_ p. 116).--It is probable that _Ornithodorus savignyi_ acts as the transmitting agent of _S. duttoni_ in places like Somaliland (Drake-Brockman, 1915).[1265] [1265] _Ibid._, viii, p. 201. *Spirochæta bronchialis* (_see_ p. 122).--The morphology and life-history of _S. bronchialis_ have been investigated by Fantham[1266] (July, 1915). From researches conducted in the Anglo-Egyptian Sudan, he found that _S. bronchialis_ is an organism presenting marked polymorphism, a feature that has only been determined by the examination of numerous preparations from the deeper bronchial regions of various patients. [1266] _Annals Trop. Med. and Parasitol._, ix, p. 391. _S. bronchialis_ varies in length from 5 µ to 27 µ, and its breadth is about 0·2 µ to 0·6 µ. These variations are due to the processes of growth and division. Many of the parasites measure either 14 µ to 16 µ long, or 7 µ, to 9 µ, the latter resulting from transverse division of the former. The ends show much variation in form, but approach the acuminate type on the whole. The discrepancies in dimensions given by the very few previous workers on the subject are probably the result of the measurement of a limited number of parasites. All such sizes can be found on some occasion during the progress of the disease, when a larger number of spirochætes is examined. The movements of _S. bronchialis_ are active, but of relatively short duration, when it is removed from the body. The number of coils of the spirochæte is rather an index of its rapidity of motion than a fixed characteristic of the species. The motile phase of _S. bronchialis_ is succeeded by one of granule formation, the granules or coccoid bodies serving as a resting stage from which new spirochætes are produced. The formation of coccoid bodies and reproduction of spirochætes from them can be observed in life. _S. bronchialis_ is a species distinct from the spirochætes occurring in the mouth. It differs from them in morphology, pathogenicity and in staining reactions. It is not a developmental form of any bacterium, and is an entity in itself. The passage from man to man is effected most probably by means of spirochætes, and especially coccoid bodies, that leave the body in the spray with expired air and by way of the nasal secretions. Owing to the fragility and short life of _S. bronchialis_ extracorporeally, the resistant coccoid bodies in air, in dried sputum and dust, and possibly also on the bodies of flies and other insects, are probably instrumental in inducing attacks of bronchial spirochætosis in human beings, especially those having a lowered bodily resistance, such as occurs after a chill. Lurie (December, 1915), has described a case from Serbia. *The Spirochætes of the Human Mouth* (_see_ p. 122).--Two species of spirochætes were recorded as occurring in the human mouth about forty or fifty years ago. These are _Spirochæta buccalis_, Steinberg (often ascribed to Cohn, 1875), and _S. dentium_, Miller (often attributed to Koch, 1877). The most recent work on _S. dentium_ and _S. buccalis_ is that of Fantham[1267] (July, 1915), who observed the parasites ascribed to Cohn and to Koch, these being the two common spirochætes seen in the mouths of natives of the Sudan and of Europeans in England, as well as the forms described and cultivated by recent investigators. Some of the mouth spirochætes are not very active, but there is marked corkscrew and boring movement, and they are flexible. Tangles or tomenta of these mouth spirochætes are common. Internal structure is seen with some difficulty, but in some specimens it can be determined, and chromatin granules are then seen. Mühlens (1907) figured stained specimens of _S. buccalis_ and _S. dentium_, in which chromatin-coloured granules were distributed along the bodies of the organisms. [1267] _Annals Trop. Med. and Parasitol._, ix, p. 402. _S. dentium_ has tapering ends, and varies in length from 4 µ to 10 µ. _S. dentium_ is rather like _Treponema pallidum_, and has been placed by some workers--for example, Dobell--in the genus _Treponema_. It has already been mentioned, on p. 128, that Noguchi cultivated three species of _Treponema_ from the human mouth--namely, _T. macrodentium_, _T. microdentium_, and _T. mucosum_, but they cannot be easily distinguished morphologically, and so may appear to be biological varieties of _S. dentium_. _S. buccalis_ has somewhat rounded or bluntly acuminate ends and varies in length from 9 µ to 22 µ. A slight membrane or crest may sometimes be observed. _S. buccalis_ was found to be the predominant spirochæte in the mouths of eight natives examined by Fantham in the Anglo-Egyptian Sudan. _S. buccalis_ and _S. dentium_ take up stains well and with relative ease. Intracellular stages of the parasites are uncommon. Multiplication by binary fission has also been observed. Coccoid bodies or granule stages of the mouth spirochætes are formed, but appear to be relatively few in number. J. G. and D. Thomson[1268] (1914) have written an interesting paper on various spirochætes occurring in the alimentary tract of man and of some of the lower animals. They have also given a useful list of references, and the work of some of the earlier authors is discussed in the paper. [1268] _Proc. Roy. Soc. Med._, vii, pt. 1, p. 47. With regard to the general morphology of spirochætes, it may be noted that the so-called axial fibre of Zuelzer is acknowledged to be homologous with the membrane or crista of molluscan spirochætes. *Coccidia in Cattle.*--Regarding the remarks on coccidiosis or “red dysentery” in cattle on p. 147, it may be added that Schultz[1269] (July, 1915) has found the malady among cattle in the Philippine Islands. He states that some irregular or atypical cases of apparent rinderpest are really due to coccidia. As has been pointed out by Montgomery, rinderpest can be transmitted by blood inoculation, while coccidiosis cannot be so transmitted, but may be diagnosed by the microscope. These differences should be remembered as the two diseases are often found to be associated and are difficult to separate clinically. Coccidia have also been found in Australian cattle. [1269] _Journ. Infect. Dis._, xvii, p. 95. *The Hæmosporidia.*--It is likely that this order (_see_ p. 151) may be soon abolished. Mesnil[1270] (April, 1915) considers that the grouping of the three families, Plasmodiidæ (or Hæmamœbidæ), Hæmogregarinidæ and Piroplasmidæ in the order Hæmosporidia is no longer possible, because of the coccidian nature of the Hæmogregarines (_see_ p. 154). The Coccidia are divisible into the Adeleidea and the Eimeridea (_see_ p. 141). The Hæmogregarinidæ are allied to the former, and the Plasmodiidæ to the latter. The Piroplasmidæ, until more is known of their life-cycle in the invertebrate host, cannot be more definitely placed. [1270] _Bull. Soc. Path. Exot._, viii, p. 241. *The Leucocytozoa of Birds.*--Regarding the statement, on p. 153, that Laveran and França consider that avian leucocytozoa may inhabit red blood cells, it may be added that França[1271] (April, 1915) remarks that the action of the parasites on the red cells is very rapid and very intense. The host cells become so altered that it is difficult to recognize their true nature. He used very young birds in his researches. Two shapes of host cell are considered, namely, those with fusiform prolongations, and those which are rounded and without such prolongations (_see_ p. 153). The movements and form of the Leucocytozoa determine the shape of the host cell, as was pointed out by Fantham[1272] in 1910. [1271] _Ibid._, p. 229. [1272] _Proc. Zool. Soc. Lond._, 1910, p. 694. Schizogony of these parasites has been seen by França (1915) and by Coles (1914), in addition to Fantham (1910), and to Moldovan (1913), mentioned on p. 153. Schizogony may also take place in the lungs of the host. The genus _Leucocytozoön_, established by Ziemann in 1898, belongs to the family Hæmamœbidæ. II.--FORMULÆ OF SOME CULTURE MEDIA. (1) *Culture Media for growing Amœbæ.*--There has been much discussion as to whether the true parasitic _Entamœbæ_ or _Endamœbæ_ can be grown on culture media (_see_ p. 42). Undoubtedly certain free-living amœbæ can be so grown, and it is considered that some of the earlier researches on the so-called artificial growth of the dysenteric amœbæ were really due to contaminations with free-living forms. The following media are worthy of note:-- Musgrave and Clegg in 1904 devised a culture medium for amœbæ. The organisms grown by them were probably not dysenteric amœbæ, as was thought, but free-living forms. Phillips[1273] (1915) gives a slightly modified formula of Musgrave and Clegg’s medium, thus:-- Agar-agar 2·5 grm. Sodium chloride 0·05 " Liebig’s beef extract 0·05 " Normal sodium hydroxide 2·0 c.c. Distilled water 100·0 " [1273] “Amœbiasis and the Dysenteries,” p. 8. Without clarifying, sterilize at 7 kilograms pressure per square centimetre for about three-quarters of an hour. It should be neutral to phenolphthalein. Anna W. Williams[1274] (1911) described a medium consisting of fresh tissue spread on agar plates for the culture of amœbæ. There are three stages in the procedure: (1) obtaining living amœbæ free from other living organisms; (2) obtaining sterile tissue; and (3) making successive transplants of amœbæ and tissue, and showing that every transplant is free from other living organisms. Each step requires many controls. The essentials of the method may now be given. Remove aseptically and rapidly the tissue required, such as brain, liver, kidney, or spleen, from a freshly killed animal (guinea-pig, rabbit, or dog). Put each tissue on a separate agar plate. Cut the selected tissue into tiny pieces, and spread them over freshly made agar plates. Place these plates in a thermostat at 36° C. for twenty-four hours to insure sterility. Add the broken up tissue to the amœbæ, free from bacteria, and maintain the cultures in thermostats, some at 36° C., and some at 20° C. to 24° C. Emulsions of liver and brain in sterile neutral glycerine may also be used. The freshly removed tissue serves as food for the amœbæ. [1274] _Journ. Med. Research_, xxv, p. 263; and _Proc. Soc. Exper. Biol. and Med._, viii, p. 56. The cultural amœbæ mentioned on p. 42 were grown on such media or modifications thereof. One modified medium actually used was brain tissue, to which blood was added from day to day, and an easily assimilable bacterium (one of the influenza group of bacilli) was present, which did not overgrow the medium at a temperature of 38° C. Different conditions of food and of temperature produced morphological variations in the cultural amœbæ. Couret and J. Walker[1275] (1913) state that they have cultivated five varieties of intestinal amœbæ, the associated bacteria having been previously separated. They used a medium consisting of agar to which sterile autolysed tissue had been added. The sterile tissue, such as brain or liver, was kept in a sterile thermostat at a temperature of 40° C. for ten to twenty days. The surface of the agar should be broken up before use, and the medium must not be too acid (not over 1·5 per cent.). They consider that autolysed tissue is necessary for the growth of Entamœbæ, and that naturally associated bacteria aid growth by autolysing the tissues. [1275] _Journ. Exper. Med._, xviii, p. 252. (2) *Culture Media for the growth of Protozoa parasitic in the Blood.*--MacNeal and Novy,[1276] in 1903, used a mixture of blood and agar for the cultivation of trypanosomes such as _T. lewisi_ and _T. brucei_. They employed varying proportions of the blood and agar, a medium consisting of two parts of defibrinated rabbit’s blood mixed with one part of agar being useful. The trypanosomes grew in the water of condensation. Some of the authors’ earlier formulæ contained different proportions of blood and agar with a little peptone, while one of these media contained meat extract, agar, peptone, salt and sodium carbonate. The temperature, like the proportion of blood and agar, varied with the trypanosome investigated, but the optimum was 25° C. [1276] _See Sleeping Sickness Bulletin_ (1909), i, No. 8, p. 287. Mathis[1277] (1906) somewhat simplified the technique of Novy and MacNeal. He collected the blood of a suitable animal, such as rabbit, cow or dog, strict asepsis not being essential. The blood was defibrinated in the ordinary way. One part of blood was added to two parts of agar at 50° C. The mixture was sterilized several times by heating to 75° C. or 100 ° C. Slopes were made and the water of condensation was inoculated with a little blood containing the trypanosomes. Blood may be obtained from a superficial vein or from the heart. [1277] _C. R. Soc. Biol._, lxi, p. 550. _Novy-MacNeal-Nicolle or N. N. N. Medium._--In 1908 C. Nicolle[1278] brought forward a modification of the Novy-MacNeal (N.N.) medium. The formula is as follows:-- Agar 14 grm. Sea salt 6 " Water 900 " [1278] _C. R. Acad. Sci._, cxlvi, p. 842. Apparently pure sodium chloride can be substituted equally well for sea salt. The mixture is placed in tubes and sterilized in an autoclave. To each tube one-third of its volume of rabbit blood, taken by aseptic puncture of the heart, is added. The salt agar is kept liquid at 45° C. to 50° C. and the blood is added to the mixture. The culture medium so prepared is maintained for five days at 37° C., and then for a few days at room temperature. This medium was devised for the cultivation of _Leishmania_ (_see_ p. 106), but trypanosomes may also be grown thereon. Subsequently, Nicolle recommended the use of citrated rat’s blood heated to 45° C. for half an hour, instead of defibrinated rabbit’s blood. On such a medium, J. G. Thomson and Sinton[1279] (1912) succeeded in growing _Trypanosoma gambiense_ and _T. rhodesiense_ (_see_ pp. 76, 83). [1279] _Annals Trop. Med. and Parasitol._, vi, p. 331. Noguchi’s media for the cultivation of Spirochætes and Treponemata are described on pp. 123, 125. Hata’s modification is discussed on p. 126. Bass’s glucose-blood medium for the cultivation of malarial parasites is described on pp. 170–172. It has also been used successfully for the cultivation of _Piroplasma_ or _Babesia_ (_see_ p. 172). III.--BRIEF NOTES ON GENERAL PROTOZOOLOGICAL TECHNIQUE. The object of this book is to give accounts of the structure and life-histories of the numerous parasitic organisms that affect man more particularly. It is, therefore, inappropriate to devote much space to a consideration of technique, regarding which many volumes have already been written. Methods of procedure are largely matters of opinion, and the technique that gives brilliant results when used by one investigator may be a complete failure in the hands of another. In the present appendix, brief notes regarding certain relatively simple methods only can be given, because the number of fixatives in use is very great; there are also large numbers of stains as well as many modifications of them, while the methods of applying both fixatives and stains are, perhaps, still more numerous. There are so many, in fact, that confusion frequently arises from the multiplicity of choice presented to the worker. Those desiring more information on the subject of technique are advised to consult the treatises of Bolles Lee[1280] and of Langeron.[1281] [1280] “The Microtomist’s Vade Mecum” (7th edition, 1913). London: J. and A. Churchill. [1281] “Précis de Microscopie” (1913). Paris: Masson et Cie. Fresh Material. (_a_) _Simple Examination._ _Fluid Substances, such as Blood and Sputum._--A small quantity of the substance to be examined is taken on a sterile platinum loop and transferred to a perfectly clean glass slide. A clean cover-slip is gently lowered on to the drop, air bubbles being avoided. The preparation is luted with vaseline or paraffin and examined first with a low power and then with a high power objective. The light is cut down by partly closing the diaphragm of the substage of the microscope. _Skin Ulcers and Similar Sores._--Scrapings are made from the edge of the sore, mixed with sterile physiological salt solution, and prepared and examined as above. _Fæces._--A small portion of fæces, or flakes of mucus (which may be blood-stained) from the same, is removed on a sterile platinum loop, spread out thinly after dilution, if necessary, with physiological salt solution on a slide, covered and examined as before. Alternatively, hanging drop preparations of blood, ulcerative tissue, or fæces, appropriately diluted if necessary with sodium citrate or physiological salt solution, may be made on a cover-slip, which is inverted over a slide with a well in it. The cover-slip is then luted and examined. For the elucidation of the developmental processes of such organisms as trypanosomes, spirochætes and piroplasms, fresh preparations may be often kept under observation longer by the use of a thermostat, maintained at or near blood heat, in which the microscope is inserted. (_b_) _Intra vitam Staining of fresh Preparations._ _Intra vitam_ staining is of service on some occasions, more particularly for the study of the nucleus and other chromatoid substances of the living organism. Two methods are in common use. In the first case, the stain, employed usually in very dilute solution, is mixed with the medium containing the organism. The latter takes up some of the stain, the amount of coloration depending on the organism concerned and on the stain employed. The commoner _intra vitam_ stains are pure, medicinal (zinc-free) methylene blue and neutral red, used in aqueous solutions. A solution of methylene blue of 1 per 1,000 of water may be tried, while neutral red in the proportion of 1 per 3,000 parts of water has proved of service. The second method of vital colouring consists in placing a drop of 1 per cent. solution of methylene blue on a slide or cover-slip, slightly spreading it, and allowing it to dry. The living organism is then placed in a drop of saline on the prepared slide or cover-slip, which is then mounted and examined under the microscope. Progressive staining of the organism occurs and its internal structure can be seen. A similar procedure may be followed for neutral red. _Intra vitam_ staining is useful for relatively large and easily deformed protozoa such as ciliates, as well as for amœbæ and flagellata of the gut. When examining very actively motile organisms, it is sometimes useful to endeavour to restrict their movements by adding a little gum or gelatine to the medium. (_c_) _Examination by aid of the Paraboloid Condenser._ The use of one of the dark-ground illuminators (so-called ultra-microscopes) is of service for the detection of minute living organisms or of organisms present in small numbers only. The forms of paraboloid condenser manufactured by the firms of Zeiss and Leitz can be recommended. For details of their methods of employment, reference should be made to the leaflets of the firms supplying the said instruments. By the use of the paraboloid condenser, the finer details of certain stages of life-cycles, such as the formation of granules in spirochætes and treponemata, can be observed more readily than by using the ordinary substage of the microscope. The use of the paraboloid condenser for the detection of small numbers of living organisms renders it of value for rapid diagnostic purposes. Stained Material. Fuller accounts of the technique of fixed and stained material will be found in Bolles Lee and in Langeron, already mentioned. _Thin Films._--For the examination of blood-inhabiting Protozoa, it is necessary to make first thin films or smears of blood. There are many ways of doing this, and opinions differ as to their respective merits. A simple method is to take a straight surgical needle about 2 in. long, the eye of which has been removed, and a clean glass slide. The patient’s skin is pricked, and when the bead of blood reaches the size of a small pin’s head, the slide is applied to the surface of the blood, about 1/3 in. from the far (left-hand) end of the slide. The shaft of the needle is laid across the drop of blood, which spreads between the slide and the needle. The latter is drawn evenly along the slide towards the right. The film is dried by waving it in the air. The film should possess a straight edge parallel with that of the slide and should be as uniform and thin as possible. Another glass slide may be used as a spreader, or a cover-slip or thin glass rod may be employed. _Thick Films._--These are of service in detecting malarial parasites or trypanosomes, especially when the parasites are few. The method of Ross, or a modification thereof, has been much used. A small drop of fresh blood is spread evenly and quickly with a needle-point over a square area somewhat less than that of an ordinary square cover-glass. The blood is allowed to dry. The film is then carefully dehæmoglobinized in water in which there is a trace of acetic acid. The dehæmoglobinizing fluid is then carefully drained off and the film again dried. It is fixed in absolute alcohol and stained with Romanowsky’s solution. A cubic millimetre of blood divided into quarters may be thus dehæmoglobinized and stained. The parasites in such a cubic millimetre of blood may be counted. Such a procedure was followed by R. Ross and D. Thomson,[1282] in determining the periodic variation of the numbers of trypanosomes in the blood of a patient, as mentioned and figured on pp. 78 and 79. [1282] _Proc. Roy. Soc._, B, lxxxii, p. 411. * * * * * For cytological details of various Protozoa, thin film preparations on cover-slips or slides are often useful. Cover-slip preparations are preferable, unless the organisms under investigation are extremely scanty. The medium containing the organisms, such as blood, lymph, intestinal contents, sputum, scrapings of ulcers, and urine, is spread thinly, either alone or diluted with a little physiological salt solution, on the cover-slip. Fixation while still _wet_ is necessary. Various methods are employed. *Fixatives.*--A useful procedure is to fix the wet film by exposure to 4 per cent. osmic acid vapour for ten to thirty seconds, then place in absolute alcohol for five minutes to harden. Grade down from absolute alcohol through 90 per cent., 70 per cent., 50 per cent., and 30 per cent. alcohols to water. Stain wet with a suitable stain such as hæmatoxylin, and gradually dehydrate by grading through the necessary strengths of alcohol, clear in xylol or other oily clearing medium and mount in Canada balsam. Other fixatives may be employed, such as are also useful for fixing pieces of tissue for sectioning. Films or smears on cover-slips while _still wet_ are floated on the surface of the fixative in a watch glass. Some good fixatives of wide application are:-- _Schaudinn’s Fluid._--This consists of a mixture of Saturated aqueous solution of corrosive sublimate 2 volumes Absolute alcohol 1 volume Two modifications of Schaudinn’s formula may be found useful. A saturated solution of corrosive sublimate in physiological salt solution may be substituted for the aqueous one, and the addition of a few drops of glacial acetic acid to either of the preceding mixtures may be made. Some workers prefer to use hot fixatives, raised to a temperature of about 50° C. Fixation by corrosive sublimate solutions must be followed by thorough removal of the mercury salt by washing repeatedly in 30 per cent. alcohol or with iodine-alcohol. _Bouin’s Fluid_, or modifications thereof, is also very useful for wet fixation. Bouin’s picro-formol solution consists of:-- Saturated aqueous solution of picric acid 30 volumes Formalin, 40 per cent. 10 " Acetic acid, glacial 2 " The best-known modification is one due to Duboscq and Brasil, and often known as _Bouin-Duboscq Fluid_. Its formula is as follows:-- Alcohol, 80 per cent. 150 c.c. Formalin, 40 per cent. 60 " Acetic acid, glacial 15 " Picric acid 1 grm. Thorough washing of the smear or cover-slip preparation with 70 per cent. alcohol until the yellow colour disappears is necessary to remove excess of fixative. Other fixatives, which may be of use, more especially for fixing small pieces of tissue for sectioning, are the solutions of Flemming (chromo-aceto-osmic acids) and of Zenker (sublimate-bichromate-acetic, with sodium sulphate). Regarding the time of fixation, there is much difference of opinion. Usually, exposure to or contact with the fixative for five minutes is sufficient in the case of films or smears. Material for sections should be cut into small cubic pieces, of a thickness of about 5 mm. (1/5 in.). One or two hours should be sufficient time for the fixation of such pieces of tissue, though some, as Langeron, prefer a longer time of fixation. On the other hand, Gustav Mann[1283] recommends a short fixation period. The excess of fixative should be thoroughly washed out of the tissue in the manner appropriate to the particular fixative used. If it is desired to keep the tissue for some time before sectioning and staining, it should be transferred to 70 per cent. alcohol. [1283] “Physiological Histology,” 1902, Clarendon Press, Oxford. When fluid fixatives are employed, large quantities of the fixing media are necessary. The volume of the fixative should be at least ten to twenty times that of the object, and the latter should be suspended in the middle of the fixative. The tissue should be fixed as soon as possible after the death of the host. For sectioning tissue parasitized by Protozoa, embedding in paraffin is generally recommended. Microtome sections should not, if possible, exceed 5 µ in thickness. Details of special procedures must be sought in larger works. *Staining.*--Here, as with fixatives, much choice is presented. The various modifications of the Romanowsky stain have aided greatly in the detection of various Protozoa parasitic in the blood. Such stains, however, leave something to be desired in the revealing of finer cytological details. Other stains, more especially the hæmatoxylins, must be employed for cytological purposes. Formulæ of some of the principal Romanowsky and hæmatoxylin stains may now be given. The underlying principle of the _Romanowsky Stain_ is the reaction between alkaline methylene blue and eosin, forming the so-called eosinate of methylene blue which stains chromatin purplish-red. A solution of medicinal methylene blue after having been subjected to the action of an alkali, such as sodium carbonate, becomes partly converted into certain derivatives, the chief of which are methylene azure and methylene violet. These substances are also present in matured polychrome methylene blue. The formula of a _slightly modified Romanowsky Stain_ which gives excellent results is given below:-- Two stock solutions are required-- Solution A.--Methylene blue, pure medicinal 1·0 grm. Sodium carbonate 0·5 " Water 100·0 c.c. Keep in a warm incubator for two or three days, until the solution is distinctly purple in colour. It improves with age. Solution B.--Eosin, water soluble, extra B.A. 1·0 grm. Water 1,000·0 c.c. This solution must be kept in the dark, in dark-tinted (amber-coloured) bottles, as unfortunately it is decolorized by light. Before use each stock solution must be diluted. Thus, make up 5 c.c. of each stock solution to 100 c.c. by adding distilled water. For staining, 1 volume of solution A is added to 2 or 3 volumes of solution B. Mix thoroughly by shaking, pour the mixture over the film, previously fixed in absolute alcohol, and stain for ten to fifteen minutes. Wash carefully in running water, then dry. The cytoplasm of a protozoan parasite will be stained blue, the chromatin purplish-red and vacuoles or very tenuous protoplasm will remain colourless. The exact proportions of solutions A and B, which must be mixed together, should be determined by experiment. Freshly mixed stain must be used on each occasion. _Leishman’s Stain_ is the precipitate resulting from the interaction of alkaline methylene blue and eosin. The washed and dried precipitate is collected and dissolved in pure methyl alcohol, which acts as a fixative; 0·015 grm. of Leishman powder may be dissolved in 10 c.c. of methyl alcohol for staining films. The film is covered with the solution for one minute, twice the volume of water is then added and mixed with the stain on the slide. The staining is then continued for five to ten minutes, and the film is finally washed with water. _Giemsa’s Stain._--This should be procured ready made. Azure II is a mixture of methylene azure and methylene blue. (Methylene azure is sometimes known as Giemsa’s Azure I.) The formula given by Giemsa himself in 1912 is:-- Azure II-eosin 3·0 grm. Azure II 0·8 " Glycerine, pure 125·0 " Methyl alcohol, pure 375·0 " The film is first fixed in absolute alcohol. The proportion of stain usually used is one drop of stain to 1 c.c. of water. Stain for about ten minutes and then wash in water. The details of the application of the Giemsa stain to films fixed wet and to sections must be sought in larger works on technique. These works should also be consulted for information regarding the use of Pappenheim’s Panchrome mixture. * * * * * There are numerous formulae of stains containing ripened _Hæmatoxylin_ or its essential principle, _Hæmatein_. A mordant is necessary, one of the alums being usually employed. The mordant may be included as an ingredient in the staining mixture, or it may be used separately as in the case of the so-called iron-hæmatoxylins, wherein ferric ammonium alum is used separately and is followed by staining with hæmatoxylin or hæmatein. A few of these stains of general application may now be mentioned. _Delafield’s (or Grenachier’s) Hæmatoxylin._ Hæmatoxylin crystals 4 grm. Absolute alcohol 25 c.c. Saturated aqueous solution of ammonia-alum 400 " Mix these ingredients, and leave exposed to light and air for three to four days. Filter and add-- Glycerine 100 c.c. Methyl alcohol 100 " Allow the mixture to stand until the colour is sufficiently deep, then filter and place in a stoppered bottle. The solution should be allowed to ripen for at least two months before use. Dilute aqueous solutions of the stain are of service for films and for sections. A trace of acetic acid may be added at the moment of use, for sharp differentiation. Ehrlich’s acid hæmatoxylin, Mayer’s hæmalum, and Mayer’s glychæmalum are also useful. Their formulæ will be found in larger works. The chief _Iron-Hæmatoxylin Stain_ is that devised by Heidenhain. Unfortunately the procedure involved is a long one, and various modifications have been made to obviate this disadvantage. Hæmatein may be used instead of ripened hæmatoxylin. One efficacious modification of Heidenhain’s stain is that of _Rosenbusch_. The smear or tissue, after fixation, must be graded downwards through the alcohols to water. Mordant for one and a half hours in a 3-1/2 per cent. aqueous solution of ferric ammonium sulphate. Stain for about three minutes in 1 per cent. solution of ripe hæmatoxylin or hæmatein in absolute or 96 per cent. alcohol, to which a drop of saturated aqueous solution of lithium carbonate, sufficient to produce a wine-red colour, has been added. Differentiate under the microscope with a very dilute solution of the ferric ammonium sulphate. Wash, gradually dehydrate, clear and mount in balsam. It must be remarked that iron-hæmatoxylin is a regressive stain, hence great care must be exercised in differentiating with the iron alum. _Gentian Violet._--A 1 per cent. alcoholic solution of gentian violet, or of methyl violet, or of crystal violet, will be found useful for staining spirochætes. _Methyl Green._--This substance is considered to be a chromatin stain, for either fresh or perhaps recently fixed tissues. A concentrated aqueous solution contains about 1 per cent. of the stain. This should be added to a 1 per cent. solution of acetic acid. It may be used for demonstrating the nuclei of ciliates. * * * * * In conclusion it is essential to remember that the actual magnification of figures of Protozoa should be given, and not merely the combination of objective and ocular that has been used, for unless the tube-length and distance of the drawing board from the ocular be also given, it is not possible to compute the magnification from such information. Drawings should always be made with the aid of a camera lucida, drawing prism or other form of projection apparatus. APPENDIX ON TREMATODA AND NEMATODA. BY J. W. W. STEPHENS, M.D., B.C., D.P.H. TREMATODA. *Artyfechinostomum sufrartyfex*, Clayton Lane, 1915.--Leiper thinks this may be the same as _Echinostoma malayanum_, Leiper, 1911, which species Odhner assigns to the genus Euparyphium. *Metagonimus* (_Yokogawa_) *yokogawai* occurs in dogs in Shanghai. Encysted cercariæ probably in the perch. *Opisthorchis sp.*--Skin covered with spines. Gut forks almost reach end of body. Œsophagus two to three times length of pharynx. Ovary multilobed. Ovary and testes in posterior fourth of body. Vitellaria end opposite the ovary. Distinguished from _O. felineus_ by presence of spines and lobed ovary; from _O. pseudofelineus_ and _O. noverca_ by the lobed ovary, and by the fact that the yolk glands do not extend as far as the anterior testis. It agrees with Poirier’s description of _O. viverrini_ in the Indian civet cat, but whether this species has spines on the cuticle is not known. _Habitat._--Man in Chiengmai (Malay States). Fifteen per cent. of prisoners in the jail showed the ova of this species in their fæces. Schistosome cercariæ. *Schistosome cercariæ* belong to the furcocercous division of the _Distomata_ cercariæ. Distomata cercariæ. _Body_ without a floating membrane. Tail absent, or if present not cleft to the base. Mouth anterior, gut forked. Oral sucker present. Ventral sucker near middle of body. Eyes generally absent. Group *Fercocercous cercariæ*. Cercariæ single (not in colonies). Tail forked at its end. Family. *Schistosomidæ.* Pharynx absent. *Cercaria bilharzia*, Leiper, 1915. Pigment spots (eyes) anterior to ventral sucker absent, cuticular keel on forks of tail absent. In _Bullinus_ sp. and _Planorbis boissyi_ in Egypt, (?) in _Physopsis africana_, South Africa. Adult form, _Schistosoma hæmatobium_. *Cercaria bilharziella*, Leiper, 1915. Cuticular keel on tail forks present. Pigment spots (eyes) in front of ventral sucker present. In _Planorbis boissyi_ and _P. mareoticus_, and in _Melania_ sp. Adult form (?). For characters of numerous other cercariæ which occur in fresh water molluscs _see_ “Die Susswasserfauna Deutschlands,” Max Lühe, H. 17 (Gustav Fischer, Jena, 1909). The characters of _Cercaria japonica_ of _S. japonicum_ in the mollusc _Katayama nosophora_ and of _C. mansoni_ have still to be defined. *Schistosoma mansoni*, Sambon, 1907. The evidence appears to be strong that terminal-spined eggs are not found in the West Indies, and that therefore the lateral-spined eggs found in fæces there belong probably to _S. mansoni_. If this be true, then the egg described by Stephens and Christophers in man in India probably also belongs to another species of Schistosome. NEMATODA. *Ancylostomiasis.*--Treatment: (1) _Oleum chenopodii_ (U.S.P.), dose ♏ x to ♏ xv on a lump of sugar, three doses at two-hourly intervals, preceded and followed by a purge. It is cheap, not unpleasant to take, and non-toxic. Effective also against _Ascaris lumbricoides_. (2) Milk of the higueron _Ficus laurifolia_. A spoonful in milk, three times daily for three days followed by a purge. Described as a harmless but very successful form of treatment. *Ground-itch.*--Completely cured in a few days by a 3 per cent. solution of salicylic acid in ethyl alcohol. Apply for five minutes twice daily. *Ascaris lumbricoides* can be kept alive for twelve days in Kronecker’s solution; NaOH 0·069 grammes, normal saline 1,000 c.c. Eggs are laid and develop in about a fortnight at ordinary room temperature. At 70° C. they are readily killed. *Filariasis.*--Dutcher and Whitmarsh have cultivated from the blood and from the exudation fluids of cases of filariasis (elephantiasis, lymphangitis, etc.), in about sixteen cases, a bacillus resembling _B. subtilis_. Controls were negative. They propose the name _Bacillus lymphangiticus_ for this organism, and they believe it to be the cause of the diseases grouped under the designation “filariasis.” *Oncocerca volvulus.*--_Unsheathed_ embryos (indistinguishable from those taken from the uterus of this worm) have been found in lymphatic glands and in the blood (if considerable pressure is used so as to squeeze out lymph at the time of taking the finger blood, otherwise none occurs in the specimens). The measurements in dried films are: Nerve ring 23·7 per cent. of length; G1 cell 69·6 per cent.; end of last tail cell 96·3 per cent; total length 274·3 µ. *Strongyloides stercoralis.*--Pathology: They occur in the wall of the intestine and may be associated with ulceration. They also occur in lymphatics and blood-vessels. BIBLIOGRAPHY. [In the following pages the letters C. f. B., P. u. Inf. are used to indicate the _Centralblatt für Bakteriologie, Pathologie und Infektions-Krankheiten_.] *(A) PROTOZOA* (pp. 25 to 210, 617 to 637, and 733 to 742). [_This list applies to the earlier literature only. More recent references are given as footnotes in the text._] (_a_) GENERAL. BÜTSCHLI, O. Protozoa in Bronn’s Klass. u. Ordn. d. Tierreichs, Leipz., 1880–1889. CALKINS, G. N. The Protozoa, Columbia Univ. Biol. Ser., vi, New York, 1901. DELAGE, Y., and E. HÉROUARD. Traité de Zool. Concr., i, La cellule et les protozoaires, Paris, 1896. FARMER, J. B., J. J. LISTER, E. A. MINCHIN and S. J. 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FANTHAM. _Rhinosporidium kinealyi_ n. g., n. sp., a New Sporozoon from the Mucous Membrane of the Septum Nasi of Man, Quart. Journ. Micros. Sci., 1905, xlix, p. 521. *Class IV.--Infusoria* (pp. 198 to 210). BÜTSCHLI, O. Studien über ... die Conjugation d. Infusorien, Abh. d. Senckenb. naturf. Ges., 1876, x. EHRENBERG, CH. G. Die Infusionsthierchen als vollkommene Organismen, Leipz., 1838. GUIART, J. Sur un nouv. infus. paras. de l’homme, C. R. Soc. Biol., Paris, 1903, lv, p. 245. HERTWIG, R. Über die Conjugation d. Infusorien, Abh. kgl. bayer. Akad. d. Wiss., 1889, ii, Kl., xvii. KENT, SAV. A Manual of the Infusoria, London, 1880–1882. MAUPAS, E. Rech. expér. sur la multipl. des Infusoires ciliés, Arch. Zool. exp., 1888 (2), vi. -- Le rajeunissement karyogamique chez les Ciliés, _ibid._, 1889, vii. STEIN, FR. V. Der Organismus der Infusionsthiere, Leipz., 1859–1867. _Balantidium coli_ (pp. 200 to 204 and 637). ASKANAZY, M. Pathog. Bedtg. d. _Bal. coli_, Wien. med. Wochenschr., 1903, liii, p. 127; Verh. d. D. path. Ges., v (1902), Berlin, 1903, p. 224. CASAGRANDI, O., and P. BARBAGALLO. _Bal. coli_ s. _Param. coli_, Catania, 1896, 8vo. COLLMANN, B. Fünf Fälle von _Bal. coli_ im Darm d. Mensch., In.-Diss., Kgsbg., Pr., 1900. EHRNROTH, E. Z. Frage der Pathogenität d. _Bal. coli_, Zeitschr. f. klin. Med., 1903, xlix, p. 321. GRASSI, B. Signif. patol. d. prot. par. dell’ uomo, Atti Accad. Lincei, Rendic., 1888 (4), iv, Sem. 1, p. 86. JANOWSKI, W. Ein Fall von _Bal. coli_ im Stuhl, Zeitschr. f. klin. Med., 1897, xxxii, p. 415. (With copious literature compiled by Shegalow, Solowjew and Klimenko.) KLIMENKO, W. Beitr. z. Pathol. d. _Bal. coli_, Beitr. z. path. Anat. u. allg. Path., 1903, xxxiii, p. 281. KOSLOWSKI, J. J. Zur Lehre v. d. Infus., die als Paras. im Verdauungskan. d. Mensch. vork., Arch. f. Verdauungskrankh., 1905, xi, p. 31. KOSSLER, K. Ein Fall von _Balantidium_-Colitis, Wien. med. Wochenschr., 1906, lvi, p. 522. MAGGIORA, A. Microsk. u. bacter. Beob. während einer epid. dysent. Dickdarmentzdg., C. f. B. u. Par., 1892, xi, p. 181. MALMSTEN, P. H. Infusorien als Intestinalthiere b. Mensch., Arch. f. path. Anat., 1857, xii, p. 302. NAGEL. Üb. ein. Fall v. Infusorienenteritis, Münch. med. Wochenschr., 1905, No. 44. SHEGALOW, J. P. Ein Fall von _Bal. coli_ bei einem 5 jähr. Mädchen, Jahrb. f. Kinderhlkde., 1899, xlix, p. 425. SIEVERS, R. Über _Bal. coli_ im menschl. Darm u. dessen Vork. in Schwed. u. Finland, Arch. f. Verdauungskrankh., 1900, v. Abstracted in C. f. B., P. u. Inf., 1900 (1), xxviii, p. 328. SIEVERS, R. Zur Kenntn. d. Verbreit. v. Darmparas. d. Menschen in Finland, Helsingfors, 1905; Festschr. f. Palmén, No. 10. SOLOWJEW. _Bal. coli_ als Erreger chron. Durchfälle, C. f. B., P. u. Inf., 1901 (1), xxix, pp. 821, 849. [Solowjew’s additional communication that appeared in “Wratsch,” 1901, Nos. 12 and 14, as well as in the “Russki Wratsch,” 1902, No. 14, has been translated into German by Klimenko (l. c.).] STOKVIS, B. J. _Paramaecium_ in sputa, Nederl. Tijdschr. v. Geneeskde., 1884 (2), xx. STRONG, R. P., and W. E. MUSGRAVE. Preliminary Note of a Case of Infection with _Balantidium coli_, Bull. Johns Hopkins Hosp., Baltimore, 1901, xii, p. 31. -- -- The Clinical and Pathological Significance of _Balantidium coli_, Dept. of Int. Bureau, Govt. Labor. Biol., Manila, No. 26, 1905, p. 1. WLAJEFF, G. Zur Frage d. Ätiol. u. Behandlg. d. Dysenterie, Wracebraja Gaseta, Kemmern, 1905, xii, p. 913; abstracted in C. f. B., P. u. Inf., 1906, i, Ref. xxxvii, p. 757. WOIT, O. Drei neue Fälle von _Bal. coli_ i. menschl. Darm., Deutsch. Arch. f. klin. Med., 1898, lx, p. 363. _Balantidium minutum_ (pp. 204 and 637). JAKOBY, M., and F. SCHAUDINN. Üb. zwei neue Infus. i. Darm. d. Mensch., C. f. B., P. u. Inf., 1899 (i), xxv, p. 487. SCHULZ. _Colpoda cucullus_ im Darm d. Mensch., Berl. klin. Wochenschr., 1899, No. 16, p. 353. _Nyctotherus_ (pp. 204 to 206 and 637). CASTELLANI, A. Observations on some Protozoa found in Human Fæces, C. f. B., P. u. Inf., 1905, i Abt. Orig., xxxviii, p. 66. JAKOBY, M., and F. SCHAUDINN. Über zwei Infus. i. Darm d. Mensch., _ibid._, 1899 (1), xxv, p. 487. KRAUSE, P. Üb. Infus. im Typhusstuhle nebst Beschreibg. einer bisher noch nicht beob. Art. (_Balantidium giganteum_), Deutsch. Arch. f. klin. Med., 1906, lxxxvi, p. 442. _Chlamydozoa_ (pp. 207 to 210). BOSC, F. J. Les malad. bryocytiques (malad. à protozoaires), II, La maladie vaccinale (_Plasmodium vaccinæ_), C. f. B., P. u. Inf., i Orig., xxxvi, p. 630; xxxvii, pp. 39, 195. -- Les malad. bryocyt., III, La variole et son parasite (_Plasmodium variolæ_), _ibid._, xxxix, pp. 36, 129, 247, 389, 594. CALKINS, G. N. The Life-history of _Cytoryctes variola_, Journ. Med. Research, Boston, 1904, xi, p. 136. COUNCILMAN, MAGRATH, BRINCKENHOFF, TYZZER, SOUTHARD, THOMPSON, BANCROFT and CALKINS. Studies on the Pathology and on the Etiology of Variola and of Vaccinæ, Journ. Med. Research, Boston, 1904, xi, 1, 1904. GORINI, C. Über die bei der mit Vaccine ausgef. Hornhautimpf. vorkomm. Zelleinschlüsse, C. f. B., P. u. Inf., 1900, i, Abt. xxviii, pp. 233, 589; 1902, i Orig., xxii, p. 111. GUARNIERI, G. Ric. sulla patogenesi ed etiol. dell’ inf. vacc. e variolosa, Arch. sci. med., Torino, 1892, xvi. -- Ulteriori ric. sulla etiol. e sulla patog. della inf. vacc., Clinica moderna, Firenze, 1897, iii. HÜCKEL. Die Vaccinekörperchen, Beitr. z. pathol. Anat. u. z. allg. Path., Supp. II, 1898. LOEFF, A. VAN DER, in Weekbl. van het Nederl. Tijdschr. v. Geneeskde., 1886, No. 46. MÜHLENS, P., and M. HARTMANN, Zur Kenntnis d. Vaccineerregers, C. f. B., P. u. Inf., 1906, i Orig., xxxxi, pp. 41, 203, 338, 435. PRÖSCHER, F. Über d. künstl. Züchtung eines “unsichtbaren” Mikroorgan. aus der Vaccine, C. f. B., P. u. Inf., 1906, i Orig., xl, 3, p. 337. PROWAZEK, S. Unters. üb. d. Vaccine, I, Arb. a. d. kais. Gesundheitsamt, 1905, xxii, p. 535. -- Unters. üb. d. Vaccine, II, _ibid._, 1906, xxiii, p. 525. SALMON, P. Rech. sur l’infect. dans la vaccine et la variole, Annal. Inst. Pasteur, 1897, xi, No. 4. SCHULZE, F. E. _Cytorrhyctes luis_ Siegel, Berl. klin. Wochenschr., 1905, No. 21. SCHULZE, W. Impfungen mit Luesmaterial an Kaninchenaugen, Klin. Monatsbl. f. Augenheilkde., 1905, xliii. -- Das Verhalten der _Cytorrhyctes luis_ in der mit Syphilis geimpften Kanin cheniris, Beitr. z. path. Anat. u. z. allg. Path., 1906, xxxix, p. 180. SIEGEL, J. Zur Kritik der bisherigen Cytorrhyctesarbeiten, C. f. B., P. u. Inf., 1906, i Orig., xlii, pp. 128, 225, 321, 480. WASIELEWSKI, V. Beitr. z. Kenntnis d. Vaccineerregers, Zeitschr. f. Hyg., 1901, xxxviii, p. 212. *(B) PLATYHELMINTHES* (pp. 211 to 359, 638 to 698 and 753 to 755). *Class II.--Trematodes* (pp. 212 to 282, 638 to 644, 753, and 754). [_N.B._--The literature, which is very comprehensive, has, up to the year 1892, been quoted and critically examined in Braun’s monograph on the Trematodes: Bd. iv, Abth. i, of Bronn’s “Klass. u. Ord. d. Thierreichs,” Leipz. Of works that have appeared later it is not possible to do more than enumerate the following.] BETTENDORF, H. Musculatur u. Sinneszell. d. Tremat., Zool. Jahrb. Anat., 1897, x, p. 307. BLOCHMANN, F. Die Epithelfrage bei Cestoden u. Trematoden, Hamburg, 1896. BRAUN, M. Arten d. Gattg. _Clinostomum_, Zool. Jahrb., 1900, Syst. xiv, p. 1. -- Trematoden d. Chelonier, Mitt. zool. Mus. Berlin, 1901, ii, p. 1. -- Trematoden d. Chiroptera, Annal. K. k. naturh. Hofmus., Wien, 1900, xv, p. 217. -- Zur Kenntn. d. Tremat. d. Säugeth., Zool. Jahrb., 1901, Syst. xiv, p. 311. -- Fascioliden d. Võgel, _ibid._, 1902, xvi, p. 1. BRUGGE, G. Zur Kenntn. d. Excretionsgefässsyst. d. Cestoden u. Tremat., Zool. Jahrb. Anat., 1902, xvi, p. 208. FISCHOEDER, F. Die Paramphistomiden d. Säugeth., Zool. Jahrb., 1903, Syst. xvii, p. 485. GRONKOWSKI, C. V. Zum feineren Bau d. Tremat., Poln. Arch. f. biol. u. med. Wiss., 1902, i. HEIN, W. Zur Epithelfrage d. Tremat., Zeitschr. f. wiss. Zool., 1904, lxxvii, p. 546. LOOSS, A. Die Distomen unserer Fische und Frösche, Stuttg., 1894; Bibl. zool., xvi. -- Rech. faune paras. de l’Egypte, I, Mém. Inst. égypt., 1896, iii, p. 1. -- Weit. Beitr. z. Kenntn. d. Tremat.-Fauna Ägypt, Zool. Jahrb., 1900, Syst. xii, p. 521. -- Über neue u. bekannte Tremat. aus Seeschildkröten, _ibid._, 1902, xvi, p. 411. MACLAREN, W. Beitr. z. Kenntn. einig. Tremat., Jen. Zeitschr. f. Naturw., 1903, xxxviii, p. 573. MONTICELLI, F. S. Stud. tremat. Endopar., I, Zool. Jahrb., 1893, Suppl. iii. ROEWER, C. F. Beitr. z. Histogenese v. Cercariaeum helicis, Jen. Zeitschr. f. Naturw., 1906, xli, p. 185. SCHUBMANN, W. Eibildung u. Embryonalentw. v. _Fasciola hepatica_, Zool. Jahrb. Anat., 1905, xxi, p. 571. ZIEGLER, H. E. Das Ectoderm d. Plathelminthen, Verh. D. zool. Ges., 1905, p. 35. _Watsonius watsoni_ (pp. 234, 235). CONYNGHAM, H. F. A New Trematode of Man, Brit. Med. Journ., 1904, ii, p. 663; Lancet, 1904, ii, p. 464. SHIPLEY, A. E. _Cladorchis watsoni_ (Conyngham), a Human Parasite from Africa, Thompson, Yates and Johnston Lab. Report, Liverpool, 1905, vi, 1, p. 129. _Gastrodiscus hominis_ (pp. 236, 237). GILES, G. M. A Report of an Investigation into the Causes of the Disease known in Assam as Kála-azár and Beriberi, Shillong, 1890, p. 125. LEUCKART, R. Die Paras. d. Mensch., 2. Aufl., ii, p. 450, where the first discovery is reported in greater detail. LEWIS, T. R., and MCCONNEL. A New Parasite Affecting Man, Proc. Asiatic Soc., Bengal, 1876, p. 182. _Fasciola hepatica_ (pp. 237 to 244, and 638). AMMON. Klin. Darst. d. Krankh. d. menschl. Auges, Dresden, 1838. BOSSUAT, E. Les helminth. dans le foie, Arch. de Paras., 1902, vi, p. 186. [The author is in error when he writes “The name _Dist. sibiricum_ originated from M. Braun”!] COE, W. R. Bau des Embryos v. _Dist. hep._, Zool. Jahrb. Anat., 1896, ix, p. 561. DUFFEK, E. _Dist. hep._ beim Mensch., Wien. klin. Wochenschr., 1902, p. 772. GAIDE, _cf._ under _Clonorchis sinensis_ (p. 787). GESCHEIDT and AMMON. Die Entoz. d. Auges, Zeitschr. f. Ophth., 1833, iii, P. 405. GREEFF, R. Über d. Vork. v. Würmern im Auge, Arch. f. Augenheilkde., 1907, lvi, p. 334. HAVET, J. Contrib. à l’étud. d. syst. nerv. d. Trémat., La Cellule, 1900, xvii, p. 351. HENNEGUY, L. F. Rech. sur la mode de form, de l’œuf du _Dist. hep._, Arch. d’anat. micr., 1906, ix, p. 47. KHOURI, A. Le Halzoun, Arch. de Paras., 1904, ix, 1, p. 78. KÜCHENMEISTER, F. On Animal and Vegetable Parasites of the Human Body, translated by E. Lankester, London, 1857. LEUCKART, R. Z. Entw. d. Lebereg., Arch. f. Naturg., 1882, i, p. 80. LUTZ, A. Lebensgesch. d. _Dist. hep._, C. f. B. u. P., xi, p. 783; xiii, p. 320. MALHERBE. Progr. méd., 1898, vii, No. 4. MARCINOWSKI, K. Das untere Schlundgangl. von. _Dist. hep._, Jen. Zeitschr. f. Naturw., xxxvii, 1903, p. 544. NORDMANN, A. V. Mikrograph. Beitr. z. Naturgesch. d. wirbellos. Thiere, Berlin, 1832, ii, p. 9. PALLAS, P. S. De infestis viventibus intra viventia, Diss. in., Lugd., Batavia, 1760. SAITO, S. Beitr. z. Kenntn. d. geogr. Verbr. d. _Dist. hep._, C. f. B., P. u. Inf., 1906, i Orig., xli, p. 822. SCHAPER. Die Leberegelkrankheit. d. Schafe, Deutsche Zeitschr. f. Tiermed., 1890, xvi, p. 1. SOMMER, L. Anat. d. Leberegels, Z. f. w. Zool., 1880, xxxiv, p. 539. STIEDA, L. Beitr. z. Anat. d. Plattw.: I, Arch. f. Anat. u. Phys., 1867, p. 52. -- Über d. angebl. inneren Zusammenhang d. männl. u. weibl. Org. b. Tremat., _ibid._, 1871, p. 31. STILES, C. W. Frogs, Toads and Carp as Eradicators of Fluke Diseases, Ann. Rep. Bur. of Anim. Ind., 1901, Wash., 1902, xviii, p. 220. THOMAS, P. The Life-history of the Liver Fluke, Quart. Journ. Micros. Sci., 1883, xxiii, p. 99. [_N.B._--A bibliography of cases has been compiled by Davaine (1877), Leuckart (1889–1894), Moniez (1896), Blanchard (1889), and Huber (1895), in addition to Khouri (l. c.).] _Fasciola gigantica_ (pp. 244, 245). COBBOLD, TH. SP. Description of a New Trematode Worm (_Fasciola gigantica_), Edin. New Phil. Journ., 1855, N.S. ii, p. 262. -- Entozoa, an Introduction to the Study of Helminthes, London, 1864, pl. i. GOUVEA, H. DE. La distomatose pulm. par la douve du foie, Thèse, Paris, 1895. LOOSS, A. Rech. sur la faune de l’Egypte, Mém. Inst, égypt., 1896, iii, p. 33. -- Obs. à prop. d’une note ... C. f. B., P. u. Inf. (1), 1898, xxiii, p. 459. RAILLIET, A. Sur une forme partic. de douve hépat. prov. de Senegal, C. R. Soc. Biol., Paris, 1895, 10e sér., ii, p. 338. _Fasciolopsis buski_ (pp. 245, 246, and 638). BUDD, G. On Diseases of the Liver, London, 1852. COBBOLD, T. SP. On the Supposed Rarity of ... _Dist. crassum_, Journ. Linn. Soc., 1875, xii, p. 285; Obs. on the Large Human Fluke, Veterinarian, 1876. GILES, G. M., _cf._ under _Gastrodiscus hominis_ (p. 784). LANKESTER, E. Manual of Animal and Vegetable Parasites (Küchenmeister), London, 1857, App. i, B. p. 437. LEIDY, J. On _Distomum hepaticum_, Proc. Acad. Nat. Sci., Philadelphia, 1873, P· 364. ODHNER, TH. _Fasciolopsis buski_, C. f. B., P. u. Inf., i Orig., xxxi, p. 573. _Fasciolopsis rathouisi_ (pp. 246, 247). POIRIER, P. Note sur une nouv. esp. de Dist. paras. de l’homme, Arch. Zool. exp., 1887 (2), v, p. 203. _Paragonimus ringeri_ (pp. 249 to 251, 639 and 640). BAELZ, E. Über paras. Haemopt., Centralbl. f. med. Wiss., 1880, p. 721. -- Über einig. neue Paras. d. Mensch., Berl. klin. Wochenschr., 1883, p. 234. INOUYE, J. Über d. _Dist. ringeri_ Cobb, Zeitschr. f. klin. Med., 1903, l, p. 120, with list of Japanese literature. JANSON, J. Die bish. in Japan bei Schweinen gef. Paras., Mitt. d. Ges. f. Natur- u. Völkerkde. Ostasiens, 1897, Heft 59–60. KATSURADA, F. Beitr. z. Kenntn. d. _Dist. westerm._, Beitr. z. path. Anat. u. z. allg. Path., 1900, xxviii, p. 506. KERBERT, C. Zur Trem.-Kenntn., Zool. Anz., 1878, i, p. 271. -- Beitr. z. Kenntn. d. Tremat., Arch. f. mikros. Anat., 1881, xix, p. 519. MANSON, P. _Dist. ringeri_, Med. Times and Gaz., 1881, ii, p. 8; 1882, ii, p. 42. MIURA, M. Fibr. Tuberkel verurs. durch Parasiteneier, Arch. f. path. Anat., 1889, cxvi. MONTEL, R. Distomiase pulm. en Cochinchine, Annal. d’ Hyg. et de Méd. Col., 1906, ix, p. 258. RAILLIET, A. Paras, des anim. domest. du Japon, Le Natural., 1891, xii, p. 143. STILES, C. W. Notes on Parasites, No. 26; _Dist._ (_Mesogon._) _westermanni_, Discovery of a Parasite of Man, new to the United States, Vet. Journ., 1894, p. 107. STILES, C. W., and A. HASSALL. Notes on Parasites, No. 50: A Muscle Fluke in American Swine, XVI Ann. Rep., Bur. of Anim. Industry (1899), Wash., 1900, p. 559. -- No. 51, The Lung Fluke in Swine, _ibid._, p. 560. TANIGUCHI. Ein Fall von _Distomum_-Erkrankung des Gehirns mit dem Symptomenkomplex von Jacksonscher Epilepsie, Arch. f. Psych, u. Nervenheilk., 1904, xxxviii, No. 1. WARD, H. B. _Dist. westerm._ in den Vereinigten Staaten, C. f. B. u. P., 1894, xiv, p. 362; 1895, xvii, p. 304. YAMAGIVA, K. Lungendistomenkrankh. in Japan, Arch. f. path. Anat., 1892, cxxvii; Zur Ätiologie der Jacksonschen Epilepsie, _ibid._, 1890, cxix. _Ophisthorchis felineus_ and _Metorchis truncatus_ (pp. 252 to 255, 261 and 262). ASKANAZY, M. Über Inf. d. Mensch. mit _Dist. felin._ in Ostpreussen u. ihren Zusammenhang mit Leberkrebs, C. f. B., P. u. Inf. (1), 1900, xxviii, p. 491; Verh. d. Deutsch. path. Ges., 1900, iii, p. 72. -- Die Ätiologie u. Path. d. Katzenegelerkrankg. d. Mensch., Deutsche med. Wochenschrift, 1904, xxx, p. 689; Verh. d. Ver. f. wiss. Heilkde. i. Königsb. i. Pr., 1904, iii, p. 3. -- Weitere Mitteil. üb. d. Quellen d. Inf. mit _Dist. felineum_, Schrift d. Phys.-oek. Ges., Königsberg i. Pr. 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