The Animal Parasites of Man

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

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

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

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

(Ferran948), filmaron oil 1·0 to 2·0 to 3·0 grm. in gelatine capsules, according to age (Bodenstein949). Brüning950,951 recommends the so-called American worm-seed oil, derived from a plant native to the United States, Chenopodium anthelminticum, Gray. It is given in emulsion (ol. chenopodii anthelm. 10·0 grm., vitelli ovi unius, ol. amygd., gi. arab. pulver. āā 10·0 grm., aq. destill. 200 grm.; f. emulsio) up to 0·25 to 0·5 grm. three times daily at one to two-hourly intervals, or as a pure oil from 8 to 15 drops in sugar and water; to be followed an hour after the last dose by oleum ricini or pulvis curellæ. If no action takes place by the afternoon, a laxative should again be given. The treatment frequently must be repeated the next day. Thelen952 appears to have had good results from this drug.

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

Oxyuris vermicularis (Oxyuriasis).

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

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

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

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

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

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

Treatment of oxyuriasis must be of a twofold nature; first, medicinal, the administration per os of vermicidal drugs in combination with purgatives; and secondly, local treatment of the gut by means of enemata, suppositories and high injections. Following the method prescribed by Ungar,972 pulv. glycyrrhizæ co. is first given in the case of smaller children, castor oil or calomel in that of those older, in order to evacuate the intestine, and four times daily on two days following one another a dose of naphthalin, not directly after meal-time, but as far as possible in the interval between two meals, and at the same time the ingestion of fatty or oily nutriment is as far as possible to be avoided. After eight days this treatment should be repeated, and under certain circumstances once again after a further interval of a fortnight. The dose varies between 0·05 and 0·1 grm. (children of 1 year old), 0·1 to 0·2 grm. (children of 2 to 3 years old) and 0·2 to 0·4 grm. (children of 4 to 10 years old). Dornblüth973 employs the same medicament in a form only slightly modified from Ungar’s method, Barbagallo974 gives internally only a purgative (decoct. sennæ cum natr. sulfur). Thymol, santonin, kousso, kamala or valerian may be tried instead of naphthalin. For enemata the following are employed: naphthalin in a solution of 1 in 50, ol. olivar. or thymol 0·1 in 200 aq. destill., diluted solutions of lysol, menthol in  1/2 per cent. oily solution, salicylate of soda in watery solution, decoctum tannaceti with santonin, with the addition of some drops of ol. terebinth. (Barbagallo). Decoctions of garlic, infusion of valerian, sulphur water (sublimate is to be avoided), aq. calcariæ, ol. olivarum camphoratum (Vignolo-Lutati). Santonin 0·1 grm. is the best to employ for suppositories.

For high injections, large quantities of plain water are employed (2 to 4 litres), or soapy water (0·2 to 0·5 per cent. solution of sapo medicatus, Heller,975 Still976),  1/2 per cent. salicylic acid solution or liq. alum. acet. (one tablespoonful to a litre of water, Dornblüth977), or gujanosol (2 to 3 to 4 to 5 per cent. solution, Rahn978). The employment of benzine for such high injections is not advisable according to the experience of Senger,979 owing to the symptoms of poisoning after the external application of benzine, at least not in the case of young children.

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

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

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

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

ARTHROPODA.

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

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

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

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

Dermanyssus gallinæ (avium).

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

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

Ixodes reduvius (ricinus).

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

Sarcoptes scabiei (Scabies).

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

The mite-tracks are fine curving lines, curved like a, u, c, or s, which appear as if they had been scratched with a fine needle. Upon closer examination with the magnifying glass one sees in their course small openings. These openings, in persons who keep themselves clean, are scarcely coloured; but in patients whose occupations necessitate their being associated with coloured or dirty substances, they are dark. The length of the tracks varies from some millimetres to 1 1/2 to 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 norvegica1027; in this the collection of crusts and scales, in which a quantity of dead mites, larvæ and ova are present, may become colossal.

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

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

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

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

The treatment (1) should be preceded by a bath with thorough soap ablution, and when the inflammatory symptoms are not too severe, with green soap. After the bath the skin is dried and the scabies remedy proper applied in warmth. Sulphur preparations receive first consideration; among such Vlemingkz’s mixture occupies a prominent position; this is rubbed in for half an hour by means of a strong camel-hair brush, to be followed by another bath and powder applications after drying. Repeat this method for three days one after the other, or for two days, and a third time eight days later. The latter method is worthy of recommendation as the ova, which perhaps resist the parasiticide action, have by this time developed into larvæ, and the latter can then be destroyed with certainty. The remaining sulphur preparations, which are specially employed in the form of ointments, are more complex, as the ointment should remain on the skin. Helmerisch’s and Wilkinson’s ointments are the kinds specially employed. Nagelschmidt1028 recommends thiopinol as a very suitable sulphur preparation in the form of baths or as a 10 or 5 per cent. ointment in the following way: Upon his reception the patient is given a thiopinol bath, in which he remains for thirty minutes. Immediately afterwards 30 to 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.

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 Sachs1029 that it should only be administered when mixed with ricinus oil, under the name of Peru oil, in applications repeated three times within thirty-six hours.

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

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

Demodex folliculorum.

It is not yet certain whether the Demodex folliculorum is capable of developing pathological conditions in man. Veiel1041 assumes that the hair follicle mite has no connection either with the formation of comedones or even with sebaceous gland disease. Kaposi1042 considers that they cause no disease in man and cannot be regarded as a cause of acne. Saalfeld1043 clearly adheres to the same standpoint, similarly so Jessner,1044 who, when discussing comedones, makes no mention of acne of hair follicle mites. Weyl1045 and Geber1046 adhere to the opinion that the presence of a Demodex in man in contradistinction to its presence in animals possesses absolutely no pathogenic influence. On the other hand de Amicis,1047 Majochi,1048 and Dubreuilh1049 report single cases of pronounced circumscribed clear brown pigmentations which they attribute to Demodex folliculorum. In all these cases, moreover, as regards localization the affection had a certain resemblance to pityriasis versicolor; nevertheless, in the scales separated off with the scalpel no fungi were found, but on the other hand Demodices in moderate quantity. In his earlier cases Majochi has seen the Demodex in the secretion from meibomian glands and had claimed it to be the excitant of chalazion and, as Mibelli1050 did, considered it to be the cause of some diseases of the eyelids. Ivers1051 found the parasite in 69 per cent. of normal borders of the eyelids, and attributes a pathological signification to it. Hünsche1052 and Mulder1053 arrive at the same conclusions; in the light of their investigations the Demodex is found as a constant accessory—certainly not in the meibomian glands, as it is limited only to the internal part of the hair follicle. Lewandowsky1054 considers that it can hardly be demonstrated at present that the same parasite which in individual specimens causes no symptoms is capable of producing pathological conditions when markedly increased in numbers.

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

Demodex folliculorum canis.

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

A. Babes1059 also reports several observations which go to show that persons who, to some extent, have been shown to have been in contact with mange-stricken dogs have been attacked by a scabies-like eruption localized over the thorax, abdomen, back and extremities; large numbers of Demodices were found in the follicular pustules. Lewandowsky1060 reports one case—that of an Italian workman, who suffered from an outbreak on the face, like impetigo; there was crust formation and at the edge of the crusts the epidermis appeared like a narrow row or border of vesicles. A small portion of the covering of the row of vesicles was lifted off, and after slight warming examined in 40 per cent. liquor potassæ. In this a large number of animal parasites of the Demodex group were found, and without doubt Demodex folliculorum canis alone. Hünsche1061 assumes that Demodex folliculorum penetrates into the tissues and produces abscesses.

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

INSECTA.

Pediculus capitis (Pediculus capitis) (Head Louse).

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

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

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

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

Pediculus vestimenti (Clothes Louse).

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

Phthirius inguinalis (Pediculus pubis) (Crab Louse).

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

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

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

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

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

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

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

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

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

Pulex irritans (Human Flea).

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

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

Dermatophilus (Sarcopsylla) penetrans (Sand Flea).

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

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

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