In the earlier history of medicine the helminthes played a great part as the excitants of many intestinal diseases and of enteric as well. Even if to-day they no longer be regarded as such, the conception that they represent the predisposing factor in typhoid infection through the injury they inflict on the mucosa (Guiart,683 Blanchard,684 Vivaldi and Tonello685) must not be summarily rejected. Vivaldi and Tonello found helminthes in 80 per cent. of their typhoid patients, numbering among these Trichocephalus dispar, Oxyuris vermicularis, Ancylostoma duodenale, and Ascaridæ. The report of Leuckart686 is here worth citing, to the effect that Thiebault never failed to find Trichocephalus in his cholera patients at Naples. Blanchard687 goes so far as to express the desire that in every febrile affection of the intestine an anthelmintic treatment with thymol should be undertaken as early as possible, even before learning the results of serum diagnosis.
The lesions of the liver and pancreas due to Ascaridæ are briefly discussed in the chapter on Ascariasis (p. 687).
A discussion of the intestinal helminthes from the clinical and therapeutical point of view follows these general considerations.
Dibothriocephalus latus.
From what is known as to the development of Dibothriocephalus latus, the way by which man is infected is self-evident: infection can only take place through the ingestion of insufficiently cooked fresh-water fish (pike, burbot, perch, grayling and vendace); what degree of temperature is necessary to kill the larval forms is still unknown. Dibothriocephalus latus lives in the small intestine of man, alone or in some numbers, frequently also together with Tænia solium. The proglottides are passed always united in large pieces, the ova are deposited through the uterine pore, while the worm is still in the intestine, so that they are easily found in the fæces. The proglottides are so characteristic that they cannot be confused with those of other species. In reference to whether age or sex is spared by D. latus, it is not possible to make any definite statement, especially so far as the endemic area is concerned, whether a person resides in it continuously or visits it, so long as his habit of life is in accordance with those of the country. Bendix688 certainly emphasizes the fact that early childhood is as a rule immune: his case was that of a child, aged 4 12 years.
Sparganum mansoni.
According to our present knowledge (Miyake689) the disease occurs almost exclusively in China and Japan. On the main island it occurs in all districts, though rarely under observation. It is especially frequent in the neighbourhood of Kioto and Osaka; these places are very near together, and between them there is mutually active intercourse, so that taken together they may be regarded as one district infested by this worm disease. As regards localization in the body, there appears to exist a certain predisposition for definite regions, for instance, the eye and genito-urinary tract. In some cases the parasite manifested the peculiarity of wandering about the body and of appearing at certain favourite points (musc. quadriceps femoris) (Hashimoto690). Most patients complain more or less of the onset of attacks of pain and of sensitiveness to pressure. In those cases in which the patients evacuated the worm during micturition, the symptoms were variable; sometimes there was tenesmus of the bladder, sometimes pains in the inguinal region, sometimes hæmaturia. None of these troubles is characteristic of the disease, and does no more than represent the symptoms that follow a mechanical irritation that any kind of foreign body may produce. Besides the onset of attacks of pain, swelling of the regions affected, if superficial, may often be recognized, when a superficial diffuse soft tumour can be felt which often gives pseudo-fluctuation. Sometimes a peculiar crackling can be detected internally, as in the making of a snowball. During the further course an abscess not infrequently forms around the worm. When the situation of the worm is superficial, “an inflammatory tumour with a tendency to migrate” is stated by Omi691 to be an important diagnostic sign. That, however, is not always the case, as the observation made by Inoye692 shows. It would be better to add to this sign the onset of paroxysmal pain and the temporary change in volume of the tumour. When once the parasite is removed, the wound heals just as satisfactorily as any other fresh wounds made at operation.
Dipylidium caninum (Tænia cucumerina).
This species belongs to parasites of rare occurrence. Up to the year 1905 Bollinger693 collected thirty-six cases from the literature, twenty-nine of which were children and seven adults. Since then some further cases have come to light, so that the number now observed amounts to ninety, and among them only eight adults. The youngest child was 6 weeks old (Köhl694), in which the first proglottides were passed when the child was 40 days old. This preponderating occurrence in children is clearly connected with the close intercourse between children and dogs, and also cats. Bollinger believes that D. caninum in reality occurs more frequently in adults than has hitherto been supposed. In addition, it must be mentioned that this species is quite unknown to many physicians, and is occasionally confused with Tænia solium. One notices almost daily a large quantity of cucumber-seed-like bodies, reddish or whitish-grey, about 1 cm. long and 2 mm. broad, discharged with the stools. Lindblad695 remarks that these bodies have lively movements, that they perish rapidly in fresh water, and become white and smooth. These Cestodes, in isolated cases, are parasitic in the intestine in large numbers. Sonnenschein696 expelled four fragments in the case of a boy, aged 4 months; Asam697 three fragments in the case of a child, aged 19 months; and Zschokke698 as many as five or six in that of a boy, aged 4. They do not always produce such striking symptoms as occurred in Pollak’s case.699 In other cases gastro-intestinal disturbances with or without fever (Krüger700), emaciation (Zschokke), or even nervous symptoms of central origin in the form of convulsions (Brandt701) have been observed. From the nature and mode of infection children must be kept from close contact with dogs and cats as much as possible to ensure prophylaxis. The appropriate treatment, as it mainly affects children, deserves special mention, whilst the expulsion of the remaining Cestodes may be described in this connection. Among the drugs one may mention flor. kousso 1·0 grm., pulpa tamar. depur. 2 grm., syrup of sugar 50·0 grm., one-third to be taken every hour (Lindblad). Kamala appears to have no effect, although Huber702 recommends it in small doses according to age from 0·5 to 3·0 grm. He warns against Filix mas preparations, which otherwise, even in early childhood, under careful dosage gives the best results. Young children are given 1·0 to 2·0 grm. extr. fil. maris, with mint syrup or raspberry syrup 30·0 grm., in the morning twice an hour by the mouth, or 1·0 grm. extr. fil. maris is mixed with syrup of mint, and given by means of a stomach tube (Rosenberg703). A few hours afterwards a mild laxative may be taken—one to two tablespoonfuls of aqueous tincture of rhubarb (Asam)—or an enema may be given. In a case reported by Sonnenschein decoction of pomegranate root had no effect, as it was vomited up.
Hymenolepis nana.
This species, very rare in Central and Northern Europe, inhabits the small intestine, especially of children; it burrows very deeply into the mucosa. Not uncommonly several thousand have been found in one case (Nicolo,704 E. Stoerk and Haendel705). It is remarkable that these Cestodes have been found so frequently post mortem and after vermifuges given for other reasons. Thus the clinical symptoms must often be very indefinite (Stoerk and Haendel), so that one may assume that only a slight percentage of cases of Hymenolepis nana come under observation and are published as such. On the other hand, it is certainly conceivable that with the large number of parasites that frequently occur in one individual a whole series of symptoms, in part quite severe, are capable of being produced. These are partly symptoms of intestinal catarrh, consisting of abdominal pains, constipation, alternating with attacks of diarrhœa, perverse appetite, and boulimia, abdominal pains of a cramp-like nature, followed by emaciation, headache, sleeplessness, pallor, lassitude, and in part nervous symptoms—epileptiform attacks without loss of consciousness, weakness of memory, melancholia, irregular febrile attacks (Lutz706). Possibly, too, Hymenolepis nana infects the urinary organs, producing true chyluria (Predtetschensky707). Stoerk and Haendel are inclined to think that this species, unlike other Cestodes parasitic in man and domestic animals, needs no intermediate host for its development, and that the larval forms (cysticercoid) live in the same host as the adults. The diagnosis is based on the demonstration of ova in the stools. As far as expulsion of this Cestode is concerned, santonin, kamala, kousso flowers and thymol appear to have no effect of importance; whilst extract of male fern, recommended by Grassi708 as a result of his considerable and successful experience, has been given, with the result that the worms really are expelled, and that after the treatment neither worms nor ova are any longer demonstrable in the stools of patients. In his cases of chyluria Predtetschensky prescribed ol. terebinth. 20 drops three times daily for a fortnight, then acid. gallic. 0·5 grm. three times a day for two days, then 1·0 grm. three times a day; the urine became clear, but whether permanent cure resulted remained doubtful.
Hymenolepis diminuta, H. lanceolata, Davainea asiatica, and D. madagascarensis possess no actual clinical interest; with regard to the latter it need only be pointed out that Bordier709 in studying a case of chyluria found this species in the kidneys of a person in Madagascar.
Tænia solium.
Tænia solium inhabits the small intestine of man; single proglottides or whole worms may get into the abdominal cavity and the bladder through fistulæ, and penetrating the abdominal wall escape outwards or become discharged with the urine. Symptoms of intestinal stenosis are certainly very rare, as in the case recorded by Steinhaus710 of a child, aged 9, the stenosis ceasing after the expulsion of the segments. The usual position of the worm in the small intestine is with the head closely adherent to the mucosa and the proglottides lying along the intestine; from time to time portions are discharged with the fæces per rectum. Its position can also be reversed, and the proglottides in the gut become thus discharged by vomiting.
The diagnosis depends upon the proglottides being generally discharged in pieces in the stools, or eventually an examination for eggs. Larval infection (Cysticercus cellulosæ) occurs also in man through auto-infection or through food.
Cysticercus cellulosæ of the skin and subcutaneous tissue occurs very seldom singly; as a rule they are found in hundreds and thousands in the same individual. They occur in different parts of the body, especially on the flexor surfaces of the extremities (generally symmetrically), small globular swellings, the size of a pea or a hazel nut, smooth, of a tough cartilaginous consistence, fairly movable under the skin, in the muscles less so. They never degenerate or cause the surrounding skin to lose its colour. It is an interesting fact that in the case described by Posselt711 nodules on the face, namely in the neighbourhood of the left cheek and behind the left ear, reformed. The following are, according to Posselt, characteristic for cutaneous tumours due to cysticerci: (1) the position in the subcutaneous connective tissue (and almost always simultaneously in the muscles); (2) the approximately equal size and regularly rounded oval form; (3) the peculiar density, almost reminding one of cartilage in its hardness and the sensation of tightly distended thick-walled bladders; (4) proportionately slight mobility; (5) with painlessness, absence of any cutaneous reaction (hyperæmia or swelling of the skin or pigmentation). The very gradual appearance generally of the tumours supports the diagnosis, and in addition to this evidence we may emphasize the preponderating liability of the upper part of the body to attack and the symmetrical arrangement of the nodules. Cutaneous and muscular cysticerci cause the most varied symptoms, sensory disturbances, abnormal sensations, depression and a feeling of weariness whenever the diseased parts are moved, weakness in the lower extremities, pains in the course of the sciatic nerve, in addition to those which simulate cramp in the calves, numbness in the hands, pains upon their being moved. In the case of a cysticercus situated in the elbow-joint, painful dragging sensation in the course of the ulnar nerve persisted. In other cases the arm was almost paralysed, or it could not be completely extended; stiffness and bending of the little finger were noticed. Cysticerci of the gluteal muscle cause trouble upon sitting and upon defæcation. Remittent unilateral headaches were present in the case of a cysticercus of the region of the right eyebrow; pains of a neuralgic character radiated from the diseased temporal region. The cysts may be inflamed and may suppurate; this especially happens in the case of solitary cutaneous and muscle cysticerci. The best treatment consists in puncture of the cysts with a Pravaz syringe and subsequent injection of a drop of 1 per cent. sublimate solution. Tincture of iodine has similarly been proposed (Wolff712). Frangenheim713 recommends early extirpation (this, however, only in the case of solitary cysts). Pelagutti714 believes that in his case diminution in the size of the cysts was obtained by the use of anthelminthic remedies continued over a long period combined with potassium iodide and calcium salts (internally). Cysticercus is very rarely found in the tongue; there the worms generally lie in front of the sulcus terminalis, corresponding to the middle of the tongue, according to Glas.715 In the case recorded by Gaetano716 (a boy, aged 10) there was a nodule on the left side of the tongue which grew very rapidly till it reached the size of a nut; it was embedded in the muscle and covered over by normal mucosa. Cysticerci are just as rare in the pleuræ, in the lungs, in the intestinal submucosa, in the submucosa of the small intestine, in the mesenteric glands, in the liver, pancreas, spleen and kidneys, in the mamma, in the heart, in the bones and in the great vessels (Huber717). Cysticercus of the eye deserves special mention; in rare cases the cysticercus has been met with in the subcutaneous cellular tissue of the eyelid, once in the muscle bundles of the musculus orbicularis. Subconjunctival cysts are found chiefly in youthful individuals. Their position is most varied, generally in the neighbourhood of the inner angle of the eye. Dilated vessels pass right over the cysts, which are generally movable, together with the base they rest upon, producing a spherical protrusion. The head of the worm can sometimes be seen shining through as a whitish speck. The only symptoms are those of a slight irritation of the connective tissue and some difficulty in closing the lid; larger cysts dislocate the globe. The diagnosis has the rapid growth of the cystic tumour to support it; there is the possibility of its being mistaken for a foreign body (Kaldrovils718). After division of the connective tissue capsule extraction is easily performed. It is most rare for the cysticercus to occur in the orbit. Suppuration of the cyst may have serious consequences for the eye. It is only exceptionally that the cysticerci gain access to the anterior chamber of the eye.
Subretinal cysticerci or those localized in the vitreous are more frequent. Upon examination with the ophthalmoscope there is seen in the vitreous a bluish bladder with a smooth surface. The head is seen as a white patch, and the circle of hooks and the suckers also come into view, also the frequent movements which the head and neck make in the vitreous. Operation generally yields good results; in rare instances the globe is atrophied and must be enucleated.
Formerly cysticerci in the brain were met with in fair frequency, but the number of such cases has generally decreased of late years in a remarkable way, in correspondence with the diminution of cysticerci, which is to be attributed to compulsory meat inspection. Whilst, for example, the post-mortem records of the Pathological Institute in Berlin before the year 1875 showed 20 per cent. cysticerci affecting the brain, this number declined later to 16·3 per cent., and of late years has fallen to 1 per cent. (Orth719). Nevertheless even now cysticercus still plays no inconsiderable part in the etiology of cerebral diseases. For example, in the clinic of de Amicis at Naples, among seven cases of cysticerci of the skin, they were found four times also in the brain (Sipari720). Cysticerci may occur in the dura mater, arachnoid, pia mater, choroid plexus, the surface of the cerebral hemisphere, the medullary substance, the ventricles, the aqueduct, the corpus striatum, corpora quadrigemina, the pineal gland, the pons, the cerebellum, the olfactory trigone, the bulb, the medulla oblongata, and the olive. They are most frequently found in the cortical substance and in the ventricles; the frequency of the latter situation may be explained by the flow of the fluid (Henneberg721). The severity of the symptoms is not always in proportion to the number of cysticerci. Cases have been known in which ten, twenty and forty cysticerci have been found (Hagen-Thorn722), and yet the clinical symptoms have been remarkably slight. On the other hand, solitary cysts may both run a course completely without symptoms and also cause the severest symptoms when located in specially important parts of the brain (crus, pons, central convolutions). In the case mentioned by Jacobson723 the invasion of the brain by cysticerci was immense; the largest cyst was found in the cerebral cortex. The chief symptoms of cysticercus of the brain substance consist in the onset of cortical epilepsy, which sometimes runs a very pernicious course, frequently with psychical disturbances, whilst paralyses are absent. Perhaps, too, the localization of pain, spontaneous and on pressure, corresponding with the points observed on the cranium, is of importance. Cysticerci may also change their position in the brain; patients who had earlier suffered from epileptiform convulsions later showed intra-ocular cysticerci after the cerebral symptoms had completely disappeared. Treatment can only be surgical; v. Bergmann724 operated in two cases with well-marked improvement. Parasites in the ventricles are especially dangerous, more especially so when free in the ventricles, and so capable of giving rise to the danger of sudden closure of the foramen of Majendie (Simmonds,725 Versé726). Stern727 states the symptoms of cysticercus in the fourth ventricle to be the following: general cerebral pressure symptoms (headache, vertigo, vomiting, somnolence, congested disc caused by internal hydrocephalus); in addition, there are symptoms which point to disease of the hind-brain—pain and stiffness in the neck, vertigo and cerebellar ataxy, violent and persistent vomiting, slowness of pulse; and lastly those rare but certain symptoms of a lesion of the bulb, such as diabetes, respiratory disturbances and paralysis of cerebral nerves, especially of the abducens. These are far less marked than the general symptoms of cerebral pressure. One characteristic is the remarkable alternation between severe general symptoms and periods of complete sense of well-being; in this way a functional nervous affection may be simulated (Jolasse728). Brun’s symptom (in the widest sense, sudden onset of violent cerebral symptoms upon change of head-posture) is a specially characteristic sign of free cysticercus in the fourth ventricle; the disease generally terminates with sudden death from cessation of the heart’s action. Defects in motor power, convulsions, implication of other nerves, are rare and unessential complications (Hartmann729). Carefully carried out, lumbar puncture may possess some diagnostic and therapeutic value. Treatment is purely symptomatic, or eventually Neisser’s ventricle puncture may be considered.
At the base of the brain the cysticerci, as a rule, assume that form which is designated as C. racemosus, and consists of rows of delicate grape-like bladders in groups, sometimes also markedly branched, but generally sterile, which develop in the meshes of the soft meninges and may envelop the nerves and vessels of the base of the brain. Such tumours bring about hydrocephalus and chronic leptomeningitis, which must be regarded as the causes of the clinical disturbances (cysticercus meningitis), attacks of loss of consciousness, dementia and apathy, dulness and confusion and headaches. In the case recorded by Meyer730 symptoms which resembled paralysis agitans were noteworthy, and defects in speech in the case recorded by Durst731 (C. racemosus in the region of the left Sylvian fossa). According to Markwald732 C. racemosus of the fourth ventricle is said to represent a characteristic clinical picture: violent headaches, attacks of vertigo followed very soon by deep coma and death in a few days. Treatment in Cysticercus racemosus is ineffectual. In the diagnosis of cerebral cysticerci in general the recognition of multiple cysticerci in the skin and muscle and of the tapeworm is of importance. In cases of cerebral diseases in which cysticerci may be a possible cause, Remmert733 recommends that the skin of the whole body should be palpated.
Cysticercus in the spinal cord and in the vertebral column is occasionally observed; as a rule, other organs, above all the brain and its membranes, are simultaneously affected. Here, too, the cysticercus occurs in two forms—sometimes the cysts are roundish or oval, solitary or multiple, and at other times Cysticercus racemosus occurs.
Tænia saginata.
Occurs in the small intestine of man. It is characteristic of the habit of life of this parasite that once it has become mature its proglottides are dropped off daily in increasing numbers because its growth is extraordinarily rapid. The joints are discharged generally spontaneously during the whole day without a stool. An extraordinarily unpleasant sensation is produced by the damp, cool joints slipping down into one’s lower garments and over one’s legs when walking; women especially, in whom the proglottides slip through their petticoats on to their legs, complain bitterly of this troublesome symptom. Another unpleasant symptom is superadded in the shape of the proglottides tickling the rectum, and this excites irritable people to the last degree. Different species of tapeworms are not mutually exclusive. B. latus and T. solium frequently occur side by side, so also T. solium and T. saginata—for instance, in a butcher’s assistant we once expelled twelve T. solium and one T. saginata at the same time. The greatest number of Tæniæ which have been observed at one time amounted to forty T. solium (Kleefeld734). Even though the cysticercus of T. saginata is not, as in the case of T. solium, particularly dangerous to man, a parasite, nevertheless, which requires so much nutrient material during its rapid growth, and thereby sets up manifold disturbances in the general condition of health, ought to be expelled as rapidly and thoroughly as possible.
Tapeworms are found not uncommonly with other intestinal parasites, such as Ascaris, Oxyuris, Trichocephalus or Ancylostoma. Prunac735 described a case in which a woman passed a Tænia through the anus while she vomited a Fasciola hepatica.
The symptomatology of these three large species of Cestodes, Dibothriocephalus latus, Tænia solium, and T. saginata, may very well be summarized together, as, apart from some peculiarities, the clinical symptoms, especially so far as their localization in the intestine is concerned, are practically the same for all three species. In a large number of cases the hosts have no suspicion whatever that they are harbouring a tapeworm; they feel quite well and free from any disquieting symptoms whatever, and only become aware of the fact that they are the carriers of a tapeworm when the discharge of the segments takes place; on the other hand, it is often difficult to rid people of the idea that they are harbouring a Tænia (Küchenmeister calls such Tænia imaginata); usually it is undigested fibrous shreds of beefsteak which are regarded by the patients as proglottides of tæniæ.
In a large number of cases, disturbances of the intestinal tract set in, e.g., sense of pressure in the abdomen, which sometimes becomes constant on one and the same side, or sometimes changes, now at the umbilicus and again at the epigastrium; here and there colicky pains are present. Derangements of appetite and digestion are frequently complained of; the most frequent are the sensations of morbid hunger or irregular appetite, nausea and vomiting. Thus, at the Third Congress of Internal Medicine, Senator recorded a case in which there were symptoms of nervous dyspepsia, cured after a successful vermifuge. There is either constipation or diarrhœa, so that many of such patients are brought for treatment with the diagnosis of “chronic intestinal catarrh” and correspondingly treated. As to the treatment of toxic action of the Tæniæ when such arises, see the special section on the subject (bothriocephalus anæmia, p. 644). The frequent disturbances of the general condition, so-called reflex phenomena, so far as the action of toxic substances is not in question, may be explained by the fact of their occurrence in specially sensitive individuals who are affected by such phenomena. The proof that a diseased condition is produced by a tapeworm will be forthcoming with some degree of certainty if the symptoms cease immediately after the removal of the parasites. As a whole series of troubles, which certainly have nothing to do with them, are erroneously ascribed to the tapeworm, as is frequently assumed, one will do well to be somewhat critical in this respect.
The treatment is of a threefold nature: prophylactic, symptomatic and radical.
Under any circumstances, the best prophylaxis is that which consists in only eating the flesh of those animals in which any of the three larval forms occur (pig, cattle, salmon, pike, burbot, etc.) so prepared that the larval forms have been destroyed and the food thus rendered innocuous. For domestic and public use the rule prescribed by Küchenmeister is under all circumstances most easily understood, namely to roast or boil till the flesh appear greyish-white and sufficiently done by reason of the coagulation of the albumen and decolorization of the blood. The general prophylaxis simply concerns the tapeworm carriers trying to limit as far as possible the further extension of the parasites in the animal world by carefully rendering the expelled segments and worms harmless (pouring sulphuric acid over the fæces and burning the worms) and also by strictly adhering to official regulations. The official system of meat inspection in this respect has been of immense service, and much can still be done by means of thorough official control over cleanliness in abattoirs and butchers’ shops. Galli-Valerio736 very rightly desires the abolition of the custom of manuring fruit-plants such as strawberries, vegetables and salad with the contents of privies, and would extend the use of privies in the country.
Symptomatic treatment consists, in the case of those Tæniæ which resist radical attempts at expulsion, of repeated use of drugs injurious to the worm as soon as ever new proglottides are formed, or in special cases, as in the case of persons weakened by diseases or operations, or frail old people, or patients with severe heart failure, gastric or intestinal carcinoma, or in pregnancy, in effecting the expulsion of a large chain of proglottides by the mildest measures possible.
Radical treatment of the Tænia is not always equally easy in all three species, even when the means used are the same; the easiest to expel is T. solium, then D. latus, and the most difficult T. saginata. That as yet no certain cure exists for Cestodes is clear from the large number of drugs recommended from time to time, and the increase of bungling treatment in this respect; in addition, there is no department in which there is so much quackery as in vermifuges. The treatment proper should always be preceded by thorough preparatory treatment, the purpose of which is to render the gut as empty as possible once for all, and on the other hand to put the worms themselves into a diseased condition. How far the host himself has been made ill by such preliminary cures (herring, pickle, garlic, onions, preserved strawberries), many a person who has had to do with such things can recount. In the opinion of Fischer737 strict preparatory treatment appears to favour the development of toxic substances, or else it disposes to vomiting; as a rule it causes the patient far more discomfort than the treatment itself. In recent times far less weight is attached to these preparatory treatments than to carefully prepared and correctly dosed drugs; the preparation is generally limited to relieving the intestine in a simple way, the day before the treatment, of the densest fæcal masses, by a simple aperient or water enema.
We recommend the following, which has always proved itself to be the best and simplest remedy against T. saginata. The patient takes early in the evening before the treatment nothing but a plate of soup or a glass of milk, and then takes a laxative (electuar. lenit or infus. sennæ compos. or an enema), so that later in the evening one to two stools are passed. In this connection we fail to agree with Grawitz738 and Boas,739 who consider that at least preliminary evacuation of the intestines can be dispensed with. On the following morning the patient should take a cup of black coffee or tea without anything else, and half an hour later the vermifuge.
The best drug is extract. filicis maris æther., which also forms the main constituent of most of the secret remedies recommended for tapeworms. Earlier mishaps with this preparation had their origin principally in insufficient dosage. Also, in addition to correct dosage, extract. filic. maris needs very careful preparation if satisfactory results are to be attained. If preparations with the trade mark “Helfenberg” or “Wohnar” are not used, but the male fern extract has been prepared by a chemist, one must make certain that the roots of the Aspidium filix-mas have been collected in May or October, and only green sappy specimens selected, and that the attached paleæ have been separated, that they have been broken up small and ether poured over them with a little spirits of wine while quite fresh. The whole mass is to be kept in a cool place, but not too closely covered. If at any time a certain quantity is to be used, it is taken out, the ether carefully distilled in a retort till the extract has a suitable fluid consistency. Fischer attaches great importance to the direction in the Pharmacopœia being exactly followed, to the effect that the extract is to be carefully stirred before prescribing, as the active substances undergo partial crystallization if kept for any length of time and sink to the bottom, so that the preparation has a different strength and toxicity in different layers. Of this extract 10 to 12 to 15 grm. are to be taken in gelatine capsules within half an hour. We consider it unjustifiable to give greater doses than 15 grm. to adults, as many cases are known in which to some extent severe toxic symptoms have followed, such as headache, sensation of giddiness, dyspnœa and cyanosis, yellow vision (xanthopsia), delirium, stupor, the most severe cramps in the extremities, rapidly fatal trismus and tetanus. The most serious are defects of vision of various kinds, which may end in amblyopia and amaurosis, with permanent blindness. A complete collection of toxicological literature up to the year 1903 is to be found in Marx’s740 Dissertation. Since that time further instances of such intoxications have been made known. Nagel741 observed them only in severe cases. O. Meyer742 lays special stress on the bad prognosis of the disturbances of vision evoked by poisoning with extract. filicis maris. Studt743 has seen two cases of optic neuritis, one with circumscribed, the other with diffuse retinal œdema. Uhthoff744 has only seen one case; in that reported by Noiszewski745 the toxic retinitis was cured; in Viereck’s746 case bilateral concentric limitation of the field of vision followed three days after taking 8·0 grm. extract. filicis maris. Stuelp747 attributes the amaurosis occurring after taking filix mas to a toxic action on the muscularis of the central retinal artery; there followed paralysis of the vessel, vascular engorgement, and thereby nutritional defects of the nervous elements followed. In children one has to diminish the dose correspondingly, as with them, still more so than with adults, severe disturbances arise. Huber748 claims that this drug should not be given to children indiscriminately. The view is frequently expressed that a combination of extractum filicis maris with fatty oils in which the active constituents are soluble favours intoxication. Marx749 also argues from this standpoint and assumes that the ideal preparation, free from objection, would be got if from filix-mas extract a preparation free from fatty oils could be made, and he considers it advisable to limit the use of castor oil as an aperient before and after taking the “cure” and to prescribe instead a saline laxative, such as Epsom salts or Glauber’s salts. Sonnenschein750 also advises against the simultaneous exhibition of extractum filicis maris with oleum ricini, as is the case with Helfenberg’s capsules, and Boas751 is likewise anxious that ol. ricini should be avoided. Lenhartz752 appears to consider the warning against the simultaneous combination of the extract with fats or ethereal oils, and especially against the employment of castor oil as an after-treatment, as without justification, and we, too, in the course of our many filix treatments, have never yet witnessed any unfavourable effect from the use of castor oil in the after-treatment. The surest way of obviating the toxic effects of extractum filicis is to give a laxative (ol. ricini) as soon as the extract has left the stomach, say, about half an hour, so that it need not stay longer than necessary in the gut and become absorbed. Perhaps in most cases of poisoning, transgressions against this rule have been the cause of the toxic action. The nausea that sets in the day after taking the drug and the inclination to vomit are best resisted by giving iced coffee, iced tea, iced pills, peppermint tea, cognac, one to two wafer powders of menthol and sacch. lactis āā 0·2 grm. (Apolant753) half an hour before the drug is taken. Fischer754 considers that lying still in the horizontal position is the best remedy. Boas755 recommends the injection of the drug into the stomachs of patients who tolerate extractum filicis badly, in the form of a thin emulsion (with gi. arab.). In the case of children the extract is prescribed with honey as an electuary. The method recommended by Fowler756 is without doubt too detailed; he prescribes before the treatment two to three to four days’ rest in bed; special diet, tablets of cascara sagrada three times daily, on the fourth day senna infusion, and then to give the extractum filicis maris in capsules in four doses, to be taken every quarter of an hour.
Under Jaquet’s757 direction, Kraft has prepared an amorphous acid from the fern root extract which is designated filmaron. As a vermifuge the drug is prescribed for children of 2 to 5 years of age in doses up to 0·2 to 0·3 grm., for children of from 8 to 12 years in doses up to 0·5 to 0·7 grm., and for adults up to 0·7 to 1·0 grm., so as to expel the parasites. Bodenstein758 gives the filmaron oil introduced into commerce by the firm of Boehringer (one part filmaron and nine parts castor oil) in still greater dosage, either fasting or, in the case of sensitive patients, one hour after a cup of tea; he gives peppermint tablets against possible nausea. Brieger759 tested the preparation in twenty-three cases; in twenty-one of these he prescribed it as an ether-castor oil mixture, and in two as capsules. The action always took effect in from two to five hours, and only in three cases were unpleasant after-effects in the shape of colic observed; in sixteen cases the result was positive, in seven negative.
The attempts made by Goldmann760 to prepare from the bark of Musenna abyssinica, a plant of the order Myrsinaceæ, indigenous to Persia, the active substance, namely sebirol, have shown that when this is given alone it certainly acts as a vermicide, but not as a vermifuge; on the other hand, the results of a combination of sebirol with thymol and salicylates were surprisingly good; this mixture has been introduced into commerce as tæniol, in the shape of pastilles prepared with chocolate for children. The method of giving tæniol is as follows: On the day before the administration a light diet and thorough purging with calomel are ordered; and then on the day of the treatment itself, after a breakfast consisting of a cup of tea, in the case of adults, thirteen to fifteen tæniol pastilles are taken in some red wine at intervals of ten minutes respectively. In the middle of this treatment an interval of some hours is interposed. After the pastilles have been taken a calomel purge is again given. The results obtained by Liermberger761 are sufficiently encouraging to be put to further test.
Fischer762 has tested in some of his cases extracts of some new species of fern root; he employed the extract from the rhizomes of Aspidium spinulosum and A. dilatatum, two fern roots indigenous to Sweden, and obtained remarkable results (doses of 4 grm.). Laurén763 had previously recorded similar results, and recently Friedjung,764 using extr. aspid. spinulos.
Cortex radicis granati as fresh bark is a very good drug, and is usually given as a decoction: 180·0 bark to 1,000·0 water, boiled for forty hours to 240·0, and a small cupful to be given every half an hour; colic, vomiting and diarrhœa, are, however, easily induced. The chief constituent of the granate root, pelletierinum, possesses vermicidal properties, and is much recommended, especially in France. Sequelæ easily arise (vertigo, hazy vision, malaise, vomiting, quickened heart’s action, muscular tremors, cramps in the calves), especially in delicate persons and children, so that one should refrain from giving it to the latter especially (Drivon765). Sometimes, judging by the experience of Sobotta766 and Boas,767 the action is problematical. Where it is desired to employ it in the case of adults, the following is prescribed: pellet. sulfur. 0·3 to 0·4 grm., acid. tannic. 0·5 grm., sir. rub. jd. 30·0 grm., to be taken at one time, and a quarter to half an hour after a purgative (senna infusion). In the case of children it is better to employ semina cucurbitæ maximæ instead of extractum filicis maris. Sixty to 100 pumpkin seeds are pounded up with sugar, which yield a pleasant-tasting electuary, and which are taken all at once; half an hour afterwards a laxative is taken (Storch,768 Pick769), Jungklauss’s preparation is nothing else than a pumpkin extract; its action is favourable; it is, however, too expensive (Ritter770). Flores kousso up to 15 to 20 grm. in compressed form or in sugar or honey in the form of electuaries (children 2·0 to 10·0 grm. according to age) is not to be relied upon; kussin, prepared from kousso flowers (Bedall, Munich), is not a pure body; when taken it is divided into four parts up to 1·0 to 2·0 grm. with elæosaccharum menthæ, at half-hourly intervals; it is said to be less unpleasant than treatment with flores kousso (Liebreich and Langgard771). Kosinum crystallisatum (dose 1·5 to 2·0 grm.) is prepared by the firm of Merck. Kamala is the least potent of the tapeworm drugs in use, and is principally to be recommended in the treatment of children: 1·5 to 3·0 grm. in electuaries. According to Leichtenstern772 and White773 chloroform, even in toxic doses, cannot do any harm to the tapeworm, nevertheless it has been recently recommended by Carratú774; chloroform 6·0, sirup. 60·0, one teaspoonful to be taken every hour (fasting). Salol is recommended by Galli-Valerio775 as an absolutely harmless tapeworm drug; thymotal (a derivative of thymol) by Pool,776 3 grm. to be given up to three to four times on four consecutive days.
The drug well known long ago, cuprum oxyd. nigr., has been recently brought into fresh notice by Dörr.777 It is also the chief constituent of the tapeworm drug introduced into commerce by the firm of Dehlsen (Itzehoe) (Koch778). The coconut is absolutely ineffectual, also naphthalin, croton-chloral, ether, gallanol, strontium lactate, glycerine and bromide of potash.
Where possible one should endeavour to discover the head or the heads of the tapeworm in the stools, so as to make certain whether the treatment has been successful; this search is best carried out by immediately and carefully pouring water over the total quantity of evacuations collected in the night stool, without stirring them up, till only the tapeworm is found lying at the bottom of the vessel.
Strongyloides stercoralis.
The pathological significance of this intestinal parasite is not yet fully demonstrated. In Seifert’s779 observation, on what Leichtenstern780 called the celebrated Würzburg case, the patient had suffered many times from attacks of blood-stained diarrhœa with tenesmus, as in Zinn’s781 case of a three year old boy who had bloody purulent diarrhœa. Schlüter782 speaks of a hæmorrhagic enteritis produced by Strongyloides. In other cases besides diarrhœa (either with or without blood) there were noted: pains in the body (Schlüter), tenderness of the abdomen, loss of appetite, gastric troubles of a general kind, headache, giddiness, fainting attacks, anæmia (Silvestri,783 Valdes,784 and Trappe785), so that even if in isolated cases (Fülleborn786) symptoms are absent, some significance cannot be denied these parasites as a matter of course (Bruns,787 Leichtenstern788). According to Kurlow,789 in Siberia there is a form of sporadic bloody diarrhœa which has its origin in the presence of Strongyloides stercoralis. The parasite does not live only in the intestinal lumen, but also in the intestinal wall, where it causes abscesses, fistulæ and effusions of blood.
Diagnosis is easily made by the detection of the actively moving larvæ in the stools.
Treatment is rather difficult, as it is not always successful in getting rid of the parasites. Authors differ as to the effectiveness of extr. fil. maris. Goldmann790 still considers this preparation as the most effective; he recommends preliminary treatment with calomel 0·2 grm. and tuber. jalapæ 0·5 grm. a day before the special treatment, which consists of gelatine capsules of 15·0 grm. extr. fil. maris (to be taken in the course of four hours); afterwards rectified oil of turpentine in gelatine capsules. The thymol treatment (vide Ancylostomiasis, p. 682), thymol alone or in combination with calomel (Schlüter,791 Valdes,792 Soussino,793 Goldmann794), has often caused diminution of the number of larvæ, but also often remains resultless. Teissier795 maintains that by degrees he procured complete cure by the administration of mercury in the form of blue pill. In our case neither thymol nor calomel, santonin, extr. fil. maris, decoct, rad. granat., had any result whatever. Davaine796 believes he attained decrease and final disappearance of the larvæ by protracted milk-cure. Santonin, tannalbin and other preparations seem ineffectual. Tannin enemata (Mildner797), high injections with starch enemata (Schlüter798), may alleviate in persistent diarrhœa. Travellers who are visiting regions the native home of Strongyloides must exercise the most extreme care and scrupulous cleanliness, and these are also necessary in patients already suffering from Strongyloides, to prevent auto-reinfection (Trappe799).
Dracunculus medinensis (Dracontiasis).
The guinea worm develops in the dermis of human beings without any symptoms; only when it is completely grown does it form boil-like, extremely painful abscesses, in the greater majority of cases in the legs, in the region of the ankle, and is accompanied by general disturbance and a feeling of heaviness, dragging and pricking of the affected part; it occurs more rarely in the arms, certain parts of the back, the head, neck, scrotum and penis; in a superficial position the worm can occasionally be felt through the skin. In most cases there is only one worm and one abscess, but here and there one finds patients with three, four or even up to eight worms, and very exceptionally still more, as in the cases described by Poupée-Desportes800 (fifty worms) and by Harington801 (seventeen worms).
Diagnosis offers no difficulty when the worms are presenting or can be felt under the skin.
The inhabitants of the native home of the guinea worm, as a rule, quietly wait till it has got so far out that it can be conveniently grasped; it is then bound round with thread and fastened between the tips of a split piece of wood and slowly wound out. In ten to twelve days it can be wound out in this way. Emily802 makes injections of a 1 in 1,000 solution of sublimate either in the neighbourhood of the worm or directly into its body. Mense803 managed to remove the worm in one sitting by laying a wad of cotton wool soaked in chloroform on the exposed portion, thus stupefying it. Our therapeutic observations (Frangenheim804) favour the free laying open of the existing abscess and the consequent complete extraction of the worm.
Prophylaxis depends on care in the use of water in the guinea worm countries, especially dangerous being permanent waters infested by Cyclops sp.
Filaria bancrofti.
The parasitism of this filaria leads to the formation of lymphangitis, elephantiasis, chyluria, orchitis, chylocele, abscesses, lymphatic varices, perhaps also to chylous ascites and chylous diarrhœa.
Lymphangitis usually attacks the extremities, beginning generally with a rigor and swelling of the lymphatic vessels with adjoining lymph glands. The lymphatics become hard, knotty and extremely painful, the overlying skin red and swollen in longitudinal lines (Looss), high fever sets in with, to some extent, severe general disturbance. After some days the attack subsides, the swelling then partially disappears, but not completely, and often abscesses develop in consequence of the lymphangitis. Children, as a rule, suffer from such lymphangitic attacks (Finucane805).
Diagnosis is not easy, for many other causes frequently produce lymphangitis.
Treatment consists in rest, raising the affected limb, applications of vinegar and alum or liquor plumbi, in some cases incisions into the swollen part under antiseptic precautions.
Elephantiasis (Arabian) is usually situated in the lower extremities, in men in the scrotum and penis, in women in the labium pudendi, mons veneris, and the mammæ; more rarely it attacks the upper extremities or, indeed, the head. The disease develops during repeated attacks, which occur at irregular intervals of weeks, months or years, of fever accompanied by symptoms of lymphangitis and erysipelas (elephantoid fever), and especially as the result of different accidental occurrences such as chills, bodily exertions, external irritation. The extremities become shapeless, heavy cylinders, the scrotum occasionally a colossal tumour, the female genitalia and the mammæ smaller or larger tumours; the penis often shares in the general thickening, the inguinal glands form large hard prominent masses, and enormous deformity is caused. The cause is more often seen in men than women, rarely in children over 10, never in younger children.
Treatment of elephantiasis of the extremities consists in raising the affected part, massage, bandaging, vapour baths; the large elephantoid tumours of the genitalia and mammæ can only be treated by operative removal.
Chyluria (hæmato-chyluria), as a rule, begins by a series of attacks and often ceases for weeks or months, the attacks being accompanied by fever, pain in the back and lumbar region, about the kidneys and in the perinæum. The attacks are separated by intervals of months’ or even years’ duration, a continuous chyluria being quite rare. The disease may last many years without the constitution being markedly weakened, but in other cases anæmia and debility ensue and result in death from marasmus. In chyluria the urine becomes completely opaque like milk; but sometimes, from the presence of blood, is of a peach-like redness: the sediment contains clotted blood, and microscopically one finds fine dust-like fat granules and red cells and leucocytes, and usually, but not always, filaria larvæ. Sclerodermia may possibly be caused by Filaria (Bancroft806).
Treatment, consists in administration of ol. santali, methylene blue (0·12 grm. dose several times daily), ichthyol (in pills from 0·5 to 1·5 grm. per day), ol. terebinthinæ (0·5 to 1·5 gr. per day), thymol (Ziemann807 had no result from either thymol or methylene blue), together with absolute rest in bed, diminution of all fatty nourishment and administration of light purgatives.
Orchitis is in acute attacks a relatively frequent symptom in the East; the chylocele is rarely marked; the fluid usually shows numerous larvæ; in the case of abscesses they are generally caused directly by the adult parasites, as they have often been found in them; varices of the lymphatic vessels are either superficial or deep; lymphorrhagia arises from rupture of the dilated vessels; chylous ascites and chylous diarrhœa may also be produced by Filariæ.
Loa loa.
Loa loa, according to modern investigations, is a parasite of the subcutaneous connective tissue of man, and its appearance in the conjunctiva somewhat accidental; in earlier times it seems to have been less common (Ziemann808). A number of cases are seen in Europe of patients who have lived in filaria regions, and on return have been found to have this Nematode in the subconjunctival tissue. Pick,809 in the case of a man who had lived in the Cameroons, found the parasites in active motion under the connective tissue of the eyeball right over the cornea; extraction was easy. Ziemann810 noted three cases of Loa loa in the eye accompanied by temporary migratory swellings in different parts of the body. In one case, observed by Wurtz and Cleri811 (a woman from the French Congo), Loa loa was the cause of intermittent elastic swellings in the subcutaneous and subconjunctival tissue (marked eosinophilia). In the case recorded by Pollack812 (for thirty years police commissioner in the Cameroons) the worm under the connective tissue of the left eye by its snake-like movements caused an unpleasant itching. With cocaine and adrenalin the worm can be made visible, and by means of a strabismus hook can be drawn out of a small wound in the connective tissue. Martens813 exhibited a Filaria extracted from the eyelid under local anæsthesia.
Trichuris trichiura.
Whilst many authors consider the whip-worm as a harmless parasite of the large intestine (Leichtenstern,814 Eichhorst,815 Askanazy816), the number of severe and even fatal cases of diseases caused by it (trichocephaliasis) increase so much that the Trichuris trichiura must be excluded from the group of harmless intestinal parasites. (For disturbances of the nervous system and of the blood [anæmia] from trichocephaliasis, see p. 650). Infection in human beings results from the eggs that have developed outside the body, which probably reach the digestive tract on the hands soiled with dirt or earth, or possibly through drinking water. (Moosbrugger817 and Kahane818 mention in their cases that the children had an absolute passion for earth-eating.) Possibly, too, patients reinfect themselves anew, as an intermediate host is not necessary.
The anterior part of the body of the parasite is usually fixed in the mucous membrane, and according to Askanazy feeds on the blood of its host. Moosbrugger,817 Schulze,819 Kahane,818 Vix,820 Girard821 and Blanchard822 all found changes in the mucous membrane of the gut, showing that the parasites had been in the gut for a considerable time. Kahane818 had an opportunity of seeing at the Pasteur Institute Trichocephali with the anterior part of the body penetrating not only the mucosa but also deep into the muscularis of the gut wall. From this mode of attachment to the wall it is easily understood how Trichocephali, especially when they are numerous in the gut, cause local irritation and inflammatory conditions consisting of frequent attacks of diarrhœa, sometimes twenty times a day, lasting for months, resisting all remedies, and often accompanied by colicky pains and symptoms of peritonitis. The stools often have blood mixed with the fluid, very glassy, jelly-like mucus, more or less abundantly as in the cases of Moesasca, Moosbrugger,817 Kahane,818 Girard,821 Poledne,823 and Rippe.824 Nausea and vomiting are rarer symptoms.
Diagnosis as a rule can only be made by microscopical examination of the stools; together with the eggs, regular and beautifully formed Charcot-Leyden crystals occur.
The prognosis is unfavourable in severe infections, in slighter cases, where only a few worms are present, the danger of important symptoms is less. Treatment consists in administration per os of vermicides and in local treatment of the large gut. A remedy which was once much used was calomel, which is much lauded by Gibson and given as follows: calomel 0·06 grm., rheum. 0·3 grm., tinct. ferri sesquichlor. 1·2 c.c., aq. dest. 90·0 grm., six dessert-spoonfuls three times daily. Rippe appears to have got no result from the use of this prescription. Thymol, especially in conjunction with local treatment of the large intestine, had unquestionably some effect in certain cases, such as those of Girard, Poledne, Hausmann, Kahane and Schiller. The local treatment of the large bowel is most effectual when high injections of water and benzine are given. Becker825 obviously used too much benzine (1 dessert-spoonful to 1 litre of water), for severe irritation was set up, whilst Peiper826 used only a few drops of benzine, 5 drops to 1 litre of water being enough (Schiller). Instead of benzine enemata, garlic, 1 per cent. thymol solution, and physiological saline injections have been used, but the benzine enemata seem to be far and away the most effective. In Schiller’s case 2,000 worms came away on the first day as the result of such a combined treatment (thymol internally and benzine enemata).