Chapter LVII: Front Matter (57)

Should an attack of the external variety of piles not result in absorption, but leave an excrescence, painless but inconvenient, and liable at any time to become inflamed, excision would be in order. Divide the integument by an incision radiating from the anus, separate the skin from the tumor down to its base, and after seizing it with toothed forceps cut it off with scissors curved on the flat. Little flaps or tabs of skin remaining after piles may be snipped off with scissors. It is not well to operate upon external piles unless they obstinately resist all milder treatment. There are frequently venous enlargements containing blood-clot, and when this condition exists proceed as follows: Pinch up the little tumor between the thumb and finger of the left hand; transfix its base with a curved bistoury, and cut out; at the same time, by pressure with the thumb and finger, extrude the clot. Fill the bottom of the little sac with cotton wool, and the operation is complete. It is not necessary in these cases to wait until the inflammation subsides before operating.

The operative treatment of the internal variety may be by strangulation, by the cautery, by the écraseur, and by the use of caustics. The former of these is the safest and most convenient method, and the one usually employed in the Pennsylvania Hospital, and should be performed in the following manner: The lower bowel having been thoroughly evacuated and the patient etherized, the operator should gently but firmly stretch the sphincter. The patient should be placed upon the side, with {925} the upper part of the body prone, the hips elevated, and the thighs flexed upon the abdomen. Transfix the largest tumor with a strong, long-handled tenaculum, cut through the skin at the base with a knife or scissors around its external half, and hand the hook to an assistant, instructing him to make gentle traction. Then encircle the mass with a stout cord if the mass is not too large, or pass a stout needle threaded with a double silk ligature, from without inward, deeply through the base of the pile, drawing it through the mucous membrane on the opposite side; cut loose the needle and tie tightly, so as to completely strangulate the included tissues on either side and leave the ends of the ligature long. Treat all the remaining tumors in a similar manner seriatim, and then with scissors cut away the strangulated bodies to within a safe distance of the ligatures, the ends of which are now to be cut off close. Place an opium suppository in the bowel, and the operation is complete.

When for any sufficiently good reason the patient will not bear the ordinary anæsthetics, it will become necessary to modify the operation as follows: The tumors having been well extruded by enema of warm water or by the efforts of the patient, bend him forward over a chair and direct an assistant to draw aside the buttocks. Then pass the double ligatures as before indicated, but refrain from tying until all the tumors are thus secured, as the operator will find it convenient to draw upon the ligatures to keep the mass of piles within view and working-distance. Then draw down each tumor, cut around its base, and tie as before; cut off the ends of the ligatures and the greater portion of each strangulated tumor, and return everything within the bowel, and follow with an opium suppository. In many cases Morton has used the nitrous oxide gas with the best results. The hook should then be withdrawn, and each knot should be drawn more firmly down prior to its reduplication. Following this procedure, if properly carried out, the tumors will change color, becoming blue, thus indicating complete strangulation.

The operation by the clamp and cautery is a good method when the hemorrhoidal tumors are small. The operation is that of Mr. Cusack of Dublin, and the clamp employed is that invented by Mr. H. Smith of London. This instrument is so well known that a detailed description of it would be unnecessary. In operating with it the tumor is to be drawn well out and the clamp applied close up to its attachment with the bowel. Strangulation is effected by means of the screw which runs through the shafts of the handles. This accomplished, the strangulated portion is cut off with scissors, which should leave a stump three-eighths of an inch long. To this stump apply the actual cautery at a dull red heat, touching its every portion, after which unscrew and remove the clamp and look for hemorrhage. Should any occur, touch the bleeding point with the hot iron. Confine the patient to bed for five or six days and give sufficient opium to confine the bowels. After this time has elapsed administer a dose of oil. Remember that but one pile should be clamped at one time. "The taking two piles into the clamp at once is sure to result in hemorrhage." Do not allow the cautery-iron to touch the clamp. After the operation return the parts within the sphincter and cut off any tabs of redundant integument with scissors.

The removal of internal piles by means of the écraseur was the favorite operation of Chassaignac, but it is a mode of procedure which is now {926} regarded with disfavor by the best surgeons on account of the liability to hemorrhage, and from the fact that troublesome and injurious contractions of the anus have not infrequently followed its use. The employment of iron or copper wire instead of the usual chain has been recommended by those who prefer this mode of operation. The plan adopted by Chassaignac was to pedunculate the piles by tying a ligature around the base and drawing them down. The chain being then applied, the strangulation and crushing off was slowly accomplished by means of the lever of the instrument. It should take from twenty to twenty-five minutes' crushing to accomplish this object.

For the treatment of internal piles by caustics Houston of Dublin used strong nitric acid. A fenestrated speculum should be employed, and the acid should be applied with a piece of wood or with a glass brush, care being taken to limit its action to the tumors, the redundant liquid being mopped up with a swab of lint or prepared absorbent cotton. The entire surface should afterward be bathed in oil. The acid is relied upon to produce a granulating surface, by the healing of which and by the subsequent contraction a cure is sometimes achieved. At best, this plan of treatment has proved tedious and unsatisfactory.

Chloride of zinc and caustic potassa are even more unsatisfactory agents for this purpose than the acid, as they are very violent in local destruction and their action is very difficult to limit. The use of caustic potassa was last revived by Amussat, but failed to find favor from his contemporaries, and soon fell into merited disuse. Van Buren says: "From recent experience with the thermo-cautery of Paquelin, I am disposed to regard it as more manageable than nitric acid, and at least equally efficient." Allingham mentions favorably the strong carbolic acid as a substitute for the nitric as an application to vascular and granular surfaces. The reckless method employed by the older surgeons of cutting off internal piles with the knife or with scissors, without any precautions against bleeding, is merely mentioned in condemnation. Usually no serious symptoms are to be expected after operations for hemorrhoids, but to this general rule there are exceptions. Morton knows of two consecutive cases of tetanus after this operation performed in a hospital in this city, and both terminated fatally. One of the most common occurrences after the ligation of piles is retention of urine, generally lasting for a day or two and requiring the use of the catheter.

HEMORRHAGE FROM THE RECTUM.--Bleeding from these parts is more usually of a venous than an arterial character, but in some cases of hemorrhoids the bleeding is either arterial or arterio-venous. The latter occurs upon the detachment of a polypus, but not necessarily of a polypoid growth. Arterial or mixed bleeding occurs in carcinoma and in rodent ulcer, and also from the stumps of badly-occluded piles. In cases of vicarious menstruation from the rectum the venous blood simply oozes from the surface of the over-congested mucous membrane. This condition should be readily diagnosed by the physical properties of the blood and from the history of the patient. In almost all cases of bleeding near the anus it will be possible to pick up the vessel or the bleeding point on a tenaculum and ligate with silk, which is the most satisfactory method to the surgeon. The rectum has been dragged down with volsella forceps to apply a ligature to a point high up, but in some of these cases the acupressure pin {927} with the twisted suture will be found more convenient. Should hemorrhage occur after the ligation of piles which cannot be checked by ligature, such as a general oozing, pass all the ligatures through a hole made in the centre of a small round sponge, then tie them across a piece of stick (thus constructing a sort of tourniquet), and twist this around. Van Buren cites a case in which a sudden laceration of the integument and sphincter occurred during forcible dilatation in a case of hemorrhoids in a very broken-down subject, with very copious hemorrhage. He passed a sponge armed with a double ligature into the bowel, and, directing an assistant to make traction upon the threads, the bleeding was checked. Injecting ice-water and perchloride of iron into the rectum will often check hemorrhage. Allingham prefers the persulphate of iron to any other styptic for this purpose. Passing fragments of ice into the bowel while holding a lump of ice upon the sacrum sometimes answers a good purpose. In many cases of secondary hemorrhage from large venous sinuses in a state of ulceration it will be impossible to ligate, and the use of the ordinary styptics will be but the waste of valuable time: the bowel must be tamponed as follows: Thread a strong silk ligature through near the apex of a cone-shaped sponge, and bring it back again, so that the apex of the sponge is held in a loop of thread. Wet the sponge, squeeze it dry, and fill its meshes with ferric alum or with persulphate of iron. Pass the left fore finger into the bowel, and upon it push up the sponge, apex first, by means of a metal rod or any other convenient body, fully five inches into the rectum. Now fill the rectum below this with cotton-wool filled with the styptic. The bowel having been completely filled, make traction upon the ligatures (thus spreading out the bell-shaped sponge), while with the other hand push up the packing. If this is carefully done no fear of bleeding need be apprehended. In these cases the patient often suffers from collections of flatus, which may be obviated at the time of packing by placing a flexible catheter in the bowel and packing around it. These plugs should remain for at least five or six days, and frequently eight or ten days are none too long. The packing must then be picked carefully away from the sponge. Agnew's rectal chemise answers the same purpose. In describing its application he says: "Through the openings at the end of the largest-sized gum catheter pass a strong silk thread; take three square pieces of the material usually known as mosquito-netting, placing them one on top of the other; at the centre of these squares or pieces make an opening, and pass the catheter through it, securing the two together by the threads. In applying the instrument the different layers of the chemise must be moistened with water, and afterward well filled with the persulphate of iron. It is then conducted some distance into the rectum on a finger previously inserted; after which it is expanded like a parachute by packing between the catheter and its hood with long strips of lint thrust up on the end of a bougie until the bowel is distended on every side. The catheter will serve to conduct away the flatus, and when, after eight or ten days, its removal becomes necessary, this is very easily effected by drawing out the ribbon-like pieces of lint which were used as packing." Another method is to stuff the bowel with fragments of sponge to which threads are tied, the ends of which, protruding from the anus, facilitate their withdrawal. In conjunction with these procedures the patient's pelvis should be elevated. {928} After excision of portions of the mucous membrane the risk of hemorrhage will be lessened by the surgeon introducing through the edges of each incision a few fine sutures.

Enormous quantities of blood may escape into the bowel after operations without any external symptom being apparent until the patient becomes pallid and weak. In other cases the patient will complain of tenesmus and desire to go to stool, or of a sensation of something trickling into the bowel. Upon the recognition of these symptoms search should at once be made for internal hemorrhage.

Rectal Alimentation.

Before taking leave of this very interesting class of diseases and of their modes of treatment, it seems proper to introduce a few remarks upon the subject of rectal alimentation, as it is now a well-recognized and much-practised means of sustaining those whose stomachs are unequal to the work which in health is so easily and unconsciously performed. In the use of the lower bowel as an absorbent surface of alimentary substances many failures have been reported, a fair proportion of which, it is safe to infer, are due to the methods employed, to the nutritive matters employed, and to the condition of the rectum at the time. Firstly, as to the state of the rectum, it must be empty. Wait a reasonable time, say an hour, after stool, so that the gut may be more passive; have the patient in the recumbent posture; direct him to resist tenesmus and to exert both the will and the muscular power to retain the aliment. The syringe must be of hard rubber, must be rectal-ended, and of the capacity of two fluidounces, and perfect in action.

The preparation to be introduced, after being warmed to a temperature of 98° or 99° F., should be very slowly injected with the syringe, which should be also warmed and oiled. The enema must never exceed in amount two fluidounces. If this be rejected, wait a reasonable time and try again, using a less amount. If tenesmus proves an insurmountable barrier to ordinary means, an opium suppository is to be introduced three hours prior to another attempt. It has been suggested, inasmuch as tenesmus is often relieved by the application of cold to the rectum, to introduce the aliment in that state; but this method is open to the objection that rectal digestion would be much less likely to take place under this condition, as the bowel would then have thrown upon it the additional work of warming up the substance prior to absorbing it.

The usual errors made in applying this means of sustaining the patient are, that the injections are too large, are too rapidly introduced, and are not of the proper temperature. Allowing an interval of eight hours between the enemata would afford three in the twenty-four hours, which method has been found to offer the best results. This must be persevered in at regular daily intervals for the patient to derive its full benefit, and there is reason to suppose that the nervous system gets expectant of these daily hours of support, as it does in the case of our ordinary meal-times. An examination of the well-formed daily stools of patients thus sustained will prove how close the analogy is between this and digestion proper.

{929} Next, as to the substances to be employed. The best of these are milk, eggs, concentrated beef-extracts or beef or chicken peptones, and brandy or whiskey of good quality. These substances may be combined in various proportions to suit the individual requirements of the case. A very good mixture for this purpose is two tablespoonfuls of milk, one tablespoonful of whiskey, and an egg, using both the yelk and the albumen. To this add a little salt. This should be well beaten up and properly warmed.

It is well to persevere in the use of these enemata even though at first most of them appear to be rejected, as after a time, the rectum becoming accustomed to their presence, absorption or so-called rectal digestion may take place. This form of alimentation should be kept in reserve in a case of chronic illness until all other methods of sustaining the patient prove insufficient to support life. It is not contraindicated even in some cases of chronic diarrhoea with persistent vomiting and loss of peptic function, advantage being taken of the intervals between the evacuations to introduce a small and very concentrated nutrient enema. In ordinary cases not complicated by diarrhoea the most convenient times will be found to be about seven o'clock in the morning, three in the afternoon, and eleven at night. Wetherill suggests the possibility of forming with solid extract of beef, pepsin, and pure suet a nutrient suppository which might be retained and absorbed in some cases in which it has been found impossible to retain the enemata. A very small addition of white wax, he thinks, would keep these solid during warm weather; if not, the suet might be replaced by ol. theobroma (as in ordinary suppositories), which is probably as likely to be absorbed as the suet.

{930}

INTESTINAL WORMS.

BY JOSEPH LEIDY, M.D.

All animals, except in general the simple cell-forms constituting the sub-kingdom of protozoa, under ordinary circumstances are more or less liable to be infested with others, called parasites, which commonly live at the expense of their hosts, frequently with little or no inconvenience, but often causing discomfort and suffering even unto death. Parasites are distinguished as external and internal, the two being mostly of a widely different character. The former chiefly pertain to the division of arthropoda, or animals with jointed limbs, as exemplified by lice, fleas, and flies of the class of insects, mites of the class of arachnides, and epizoans and isopods of the class of crustaceans.

Internal parasites, from their usual habitation named entozoa, are commonly observed in the intestines of animals, and hence their distinction as intestinal worms. The name has proved to be appropriate, for investigations have shown that most entozoa, observed from time to time in other parts of the bodies of animals, pass part of their life in the intestinal canal of the same or of some other animal.

By far the greater number of entozoa are peculiar animals, constituting the chief part of the scolecides, an extensive group of the sub-kingdom of vermes or worms. Of this group they comprise the orders of CESTODES, or tape-worms; the ACANTHOCEPHALI, or thorn-headed worms; the TREMATODES, or fluke-worms; and the greater portion of the NEMATODES, or thread-worms. Many entozoa also belong to the protozoa, but these, so far as relates to man in a medical point of view, appear unimportant, and will therefore not here enter into consideration.

In the course of their life entozoa undergo changes of form and condition, and pass these in different organs of the same or of different animals, and it may be for a brief period externally or in a non-parasitic state. In many instances, as in the tape-worms and the fluke-worms, the transformations accompanying the changes are of so extraordinary a character that until their life-history was investigated the successive metamorphoses were viewed as distinct animals. Mostly, the entozoa pass one stage of existence within the intestine of some animal, and another stage in different organs of other animals. Many, perhaps most species, in each stage are peculiar to one or a few nearly-related animals, but others of the same kind infest a number of different animals. The animals infested by the same parasite may be remotely as well as nearly related. Thus the Tænia saginata, or beef tape-worm, in the mature state lives in the small intestine of man {931} only, but in its juvenile or larval condition in the flesh meat of the ox. The Tænia elliptica, the common tape-worm of the intestine of the dog, in the larval condition lives in the louse of this animal. The liver-fluke, Distomum hepaticum, occasionally found in the liver of man, but of common occurrence in the sheep, to which it proves so destructive in the affection known as rot, in the juvenile condition lives in a little fresh-water snail of the genus Lymneus. The guinea-worm, Filaria medinensis, which in the mature state is found beneath the skin of man, in the larval condition inhabits the minute crustacean cyclops of stagnant waters.

As would be reasonably supposed, entozoa commonly gain access to their hosts through the food and drink, though in the case of aquatic animals they also obtain entrance directly through the integument from the surrounding medium. So long as they remain in the intestinal canal they may occasion little trouble or inconvenience. When they are numerous in this position or proportionately large, according to their peculiar nature they may produce more or less suffering and even the most serious consequences. Generally, however, it is when they occupy other positions, to which they have migrated from the intestine, that they induce aggravated symptoms proportioned to their numbers and the nature of the organs they infest.

Many species of entozoa have been discovered in man, and most of them are peculiar in kind. Many are common, and, while some are widely extended, others are more or less restricted to certain localities. They are variable in their frequency, largely proportioned to the prevalence of habits which are favorable to their transmission, and which, though under control, are more or less disregarded. Some species are so rare in their occurrence that they seem to be accidental, and therefore of comparatively little interest to the physician.

In general, the frequency of occurrence of intestinal worms is proportioned to the extent of use of uncooked or insufficiently cooked meats, the drinking of unfiltered standing waters, uncleanly habits, and the intimacy of association with domestic animals. It therefore follows that important prophylactics against infection by parasites are properly-cooked food, the use of spring or freely-running water or filtered standing water, cleanly habits, and the avoidance of intimacy with domestic animals.

The Cestodes, or Tape-worms.

Tape-worms in the mature condition inhabit the intestines of vertebrate animals, and are usually conspicuous for their long, tape-like appearance and jointed character. In the juvenile or larval state they infest the various organs, except the interior of the intestinal canal, of both vertebrates and invertebrates, and in this condition are so diminutive and inconspicuous that until a comparatively recent period they for the most part remained unnoticed, and when known their relationship with the mature forms was not recognized.

The mature tape-worm, as ordinarily observed, is a long, soft, flat, white worm, which from its resemblance has received its familiar name. {932} It has a small head, succeeded by a short, more slender neck gradually widening into the body, which is divided transversely into segments. These, which are usually called joints or links, and also named proglottides, are so many individuals, and finally become separated to hold an independent existence. The tape-worm clings to the mucous membrane of the intestine by its head, which is provided for the purpose with suckers, and in many cases also with circlets of hooks. The segments of the body are incessantly produced by gradual growth and successive division of the neck, and as they enlarge they become more distinct and develop within a bisexual generative apparatus for each. The worm has neither mouth nor intestine, but is nourished by imbibition from the surrounding liquid in which it lies constantly bathed. A pair of longitudinal vessels commences in the head and extends throughout the body, one on each side, and in some genera is joined by a transverse vessel at the fore and back part of every segment. The mature segments have no body-cavity, but are occupied with a complex bisexual generative apparatus, which is self-impregnating. Finally the uterus, usually much ramified, becomes especially conspicuous through distension with eggs, and the rest of the organs for the most part become atrophied. The ripe segments successively detach themselves from those in advance, often singly and not infrequently several linked together. In this condition, often in lively movement, they are discharged with the feces, and thus commonly render themselves obvious to their host. Subsequently they may continue to live a brief period externally in a non-parasitic condition. Ordinarily, in moist excrement, or in water or similar materials, they will remain alive for several days.

After the discharge of the tape-worm segments, together with the eggs which had been previously laid by the latter and those still contained within them, any or all may be swallowed by animals feeding in places where the infected excrement has been deposited. When the proglottides and eggs are taken into the stomach they are digested and the embryos or proscolices are liberated.

The embryo or proscolex of the tape-worm is a microscopic spherical or oval body, provided at one pole with three pairs of divergent spicules, by which it is enabled to penetrate the walls of the stomach or intestine of its host. From these positions the embryo migrates either directly or through the blood-vessels to some other organ, most frequently the liver or the muscles. Having reached its destination, it becomes fixed in position, and for a time remains comparatively quiescent, but undergoes further development. The embryo loses its spicules and is transformed into the larval form or scolex. In most species of tape-worms the scolex is simple or individual in character, and consists of a head like that of the parent or mature worm, with a neck ending in a capacious cyst, within which the head and neck are inverted. In this form the scolex is contained in a sac of connective tissue induced by the presence of the parasite. Such sacs, frequently observed imbedded in the flesh, liver, lungs, and other organs of animals, are familiarly known as measles. In this condition the scolices of certain tape-worms have long been known, but as their relationship was not recognized, they were viewed as distinct species of parasites and described as cysticerci. In other species of tape-worms the scolex is of compound character; that is to say, the embryo {933} in its further development gives rise to the production of one or more groups of individuals in conjunction. The compound scolex thus forms a sac or a group of sacs, the basis of hydatid tumors. These occur of various sizes, even up to that of a child's head, and may occupy any organ of the body. They consist of a spherical sac or group of sacs, simple in character or containing others, ranging in size from that of a mustard-seed to that of a marble, or larger to that of a walnut, enclosed in an envelope of connective tissue induced by the presence of the parasite. The sacs are filled with liquid, and have, attached within or free and floating, or less frequently attached without, variable numbers of little white grains, which on examination with the microscope exhibit the same constitution as the simple scolex above described. As in the case of the cysticerci of measles, the scolices of hydatids have long been known, but as their relationship with the mature forms was unrecognized until lately, they were regarded as distinct parasites and described as echinococci and coenuri. Sometimes the compound scolex fails in development further than the production of the sacs, which then constitute the so-called acephalocysts.

Measles with their occupants, when retained in the muscles or other organs, ordinarily undergo no further development, but ultimately, after some months to a year or two, undergo degradation. The larva or scolex dies and atrophies; the measle degenerates, and often becomes the focus of calcareous deposit, shrinks to a little cicatrix, and may finally disappear. Of a more serious nature is the tape-worm embryo which produces the hydatid tumor. With the increase of this, proportioned to the production of sacs and scolices, it may become so large as greatly to interfere with the function of the organ it occupies, and according to the nature of this organ will be the gravity of the affection.

When, however, the flesh or other parts of animals affected with measles or hydatids containing active scolices are used as food in a raw or insufficiently cooked state, the meats are digested in the stomach and the scolices liberated to pursue their further development. Passing into the small intestine, the active scolex everts its head from its caudal sac, which atrophies and disappears, and the parasite attaches itself to the mucous membrane, and rapidly develops and grows into the conspicuous and familiar form of the adult tape-worm. The duration of life of the latter while maintaining its position in the intestine is uncertain, but under favorable circumstances it commonly continues for years, and thus, with the incessant production of ripe segments charged with eggs, it becomes a constant focus of infection.

* * * * *

Three species of tape-worm in the mature condition are common parasites of man, living in the small intestine. They are the Tænia saginata, Tænia solium, and Bothriocephalus latus.

* * * * *

TÆNIA SAGINATA.--SYNONYMS: Tænia mediocanellata; Beef tape-worm; Unarmed tape-worm; Fat tape-worm.

Larval condition: Cysticercus saginata; Beef measle-worm.

This, which is now regarded as the most common tape-worm of man, is named the beef tape-worm because it is derived from the beef used as food. In the mature condition it lives only in the small intestine of {934} man, and in the juvenile condition it lives in the ox. Its frequency is proportioned to the prevalence of the custom of eating beef in a raw or insufficiently cooked state, conjoined with the careless habit of leaving human excrement in pastures where it is accessible to cattle.

The mature beef tape-worm is commonly observed as a soft, yellowish-white, thickish, band-like worm, ranging from six to twenty feet or more in length. The head, about the size of a yellow mustard-seed, is rounded quadrate and provided with four equidistant hemispherical suckers. Succeeding the head is a short, slightly narrower, flattened neck, which merges into the gradually widening and segmented body. The segments, at first narrow fore and aft and several times wider than the length, become successively larger, proportionately longer, more distinct, and quadrate in outline; and finally the length may exceed the breadth two or three times. A full-grown tape-worm may possess twelve hundred segments and more, and specimens are recorded as reaching a length of thirty feet. The larger segments measure from a quarter of an inch to an inch long and from three to four lines wide. The larger or riper segments exhibit on one border, irregularly alternating on the two sides, at or near the middle, a papilla in which is the external aperture of the genital apparatus. In the fully-ripe segments the uterus, distended with eggs, may be obscurely seen through the wall of the body, but is rendered more visible by drying the segments, moderately compressed, between two pieces of glass. It appears as a long, narrow, white or brownish median line or tube, giving off laterally numerous short, transverse, more or less branching tubes.

The worm in its usual position lies along the course of the intestine in loose coils, and exhibits lively movements, alternately shortening and elongating, expanding and contracting the head, and protruding and retracting the suckers. The ripe segments spontaneously detach themselves, and may be found scattered along the large intestine ready to be discharged with the excrement, or, as is sometimes the case, they may spontaneously creep from the anus. Rarely more than a single worm infests a person at the time. The species is of rapid growth. According to Perroncito, quoted by Cobbold, a mature worm was reared from a beef measle, swallowed by a student, in fifty-four days.

It is estimated that the number of eggs in the mature segments of the beef tape-worm amounts to about 35,000. As the full-grown worm may consist of 1200 segments, and there is reason to believe these are renewed several times annually, we learn that the whole number of eggs produced by a single individual is enormous. The ripe segments, attached to the parent or becoming spontaneously detached, lay their eggs in the intestine to be discharged with the feces. When more or less emptied they shrink and appear reduced in size, and in this condition are expelled or spontaneously creep from the anus. If the ripe segments are forcibly expelled and are alive, they will lay their eggs in the feces externally. The ripe eggs are brown, oval, about 0.03 mm. long, and have a thick shell, with an outer vertically striated envelope.

As previously intimated, the common source of the beef tape-worm in man is the use of raw or insufficiently cooked beef affected with measles. The ox becomes infested by swallowing the eggs, or, it may be, even the entire segment, of a tape-worm deposited with feces in the {935} pastures of cattle. The measles usually occur in the muscles, including the heart, though they have also been noticed in the liver and lungs. They appear, in beef, as oval, whitish bodies from the size of a mustard-seed to that of a pea. They consist of a sac of connective tissue containing the larval tape-worm or cysticercus. Measles under ordinary circumstances are seldom noticed in beef, and when they occur are commonly few in number.

According to the latest authorities--Leuckart, Cobbold, Stein, and others--the beef tape-worm is the most common of the cestodes which infest man. Until within about thirty years it was generally not distinguished from the pork tape-worm, and this was accordingly regarded as the most common human species. Since the writer distinctly recognized the beef tape-worm within the last twenty years, all the specimens of Tæniæ, from people of Philadelphia and its vicinity, that have been submitted to him for examination--perhaps in all about fifty--have appeared to belong solely to Tænia saginata. The prevalence of this species with us is no doubt due to the common custom of eating underdone or too rare beef, while the pork tape-worm is comparatively rare, as with us pork is only used in a well-cooked condition.

* * * * *

TÆNIA SOLIUM.--SYNONYMS: The Pork tape-worm; Solitary tape-worm; Armed tape-worm.

Larval condition: Cysticercus cellulosæ; Pork measle-worm.

Until a recent period this species was generally regarded as the most common tape-worm of man--a view which in great measure was due to the circumstance that the beef tape-worm was not distinguished from it. It was called the solitary tape-worm, still expressed by the specific name, from the impression that it rarely occurred otherwise than single at a time in a person. This has also proved to be incorrect, likewise due to the two kinds of tape-worms having been confounded together; for while the beef tape-worm most commonly occurs solitary, the pork tape-worm not unfrequently occurs with several together.

The species is now appropriately named the pork tape-worm, as indicating its common source--pork used as food. The frequency of the parasite is proportioned to the prevalence of the custom of using pork in a raw or imperfectly cooked state, conjoined with that of depositing excrement where it may be accessible to hogs. In the mature condition the pork tape-worm is peculiar to man and lives in the small intestine, but in the larval condition, though especially infesting the hog, it also occasionally infests man, and lives in any organs of the body, but mostly the muscles, liver, and lungs.

The mature pork tape-worm, as commonly seen, is a soft white, thin, band-like worm, from five to ten feet long and about four lines where widest. The head is spheroid, about the size of that of an ordinary pin, and smaller than that of the beef tape-worm. It is furnished with four hemispherical cup-like suckers, and the summit forms a blunt papilla armed with a double circle of twenty-five or twenty-six hooks. The neck is narrow, thread-like, about an inch long, and merges into the segmented body, which gradually widens to the extent mentioned. The segments, at first much wider than long, as they successively enlarge also become more distinct and proportionately longer, so that the more {936} posterior ripe ones are as long as they are wide, and often longer, though not to the same degree as in the beef tape-worm. The genital papilla, with its external aperture, is marginal as in the latter. The fully-developed uterus is quite distinctive in character from that of the beef tape-worm. The median tube is coarser, and the lateral branches are likewise coarser, much fewer--half the number or fewer--less branched, and less crowded. The ripe and often spontaneously detached segments are commonly longer than broad, more or less elliptical in outline, with truncated ends, and usually measure about half an inch in length by about a third in breadth. The ripe eggs resemble those of the beef tape-worm, but are usually spheroid in shape.

The common source of the pork tape-worm is pork affected with measles eaten in the raw or insufficiently cooked state. The hog becomes affected with measles when it has access to human excrement containing eggs and ripe segments of the tape-worm, which it eats with avidity. The eggs, with their already developed embryos, when swallowed, undergo the same series of transformations and course as those indicated in the account of the beef tape-worm. Pork affected with measles is much more common than beef affected in the same way, and is frequently a subject of ordinary observation. From the difference in habit of the hog and ox this is what might have been suspected; and the fact that the beef tape-worm is more common than the pork tape-worm is to be explained from the circumstance that fresh beef is in more general use than pork, and is usually employed less thoroughly cooked.

The pork measles are commonly seen as round or oval, hard, whitish bodies, from the size of a hempseed to that of a pea, imbedded in the connective tissue of the muscles or flesh. The measle consists of a sac of connective tissue enclosing the scolex or larval tape-worm, which resembles that of the beef tape-worm, but differs especially in the possession of a double circlet of hooks to the head, as in the adult worm. The scolex has long been known, and was regarded as a distinct parasite, with the name of Cysticercus cellulosæ. When fresh pork measles are swallowed by man they are digested in the stomach, and the cysticercus or scolex is released and passes into the small intestine. Here, attaching itself to the mucous membrane by means of its suckers and crown of hooks, it rapidly develops and grows into the adult tape-worm. In this condition it lies in loose folds along the intestine, to which it clings so tenaciously that commonly the neck gives way when the greater part of the worm is forcibly detached by the use of medicines. Fragments, consisting of the more mature segments, frequently appear detached from the posterior part of the worm, and the fully-ripe segments may be seen scattered singly in the course of the large intestine. The isolated segments are thinner and more translucent than those of the beef tape-worm, and in this condition are discharged with the feces, but may also spontaneously creep from the anus, though seldom as compared with the other species.

Experiments repeatedly made by swallowing pork measles prove that the mature tape-worm may be developed in the course of three months. The length of life attained by it under favorable circumstances is uncertain, but it probably continues a dozen years or more.

The scolex of the pork tape-worm, or the cysticercus, so common in the hog, is also less frequently a parasite of man, and in this condition is a {937} more potent agent of danger than in its ordinary or mature state. The infection is due to the introduction of eggs or mature segments of the tape-worm into the stomach--a circumstance which may readily occur through handling these objects and transferring them to the mouth, or more rarely perhaps by their transference from the intestine into the stomach through vomiting.

In the measle form the parasite may occur in any organ of the body, but is mostly found in the muscles and subcutaneous tissue. Its pathological significance depends on its number and position. Located in the nerve-centres, it may occasion the most serious consequences. Usually it occurs in small numbers and gives rise to no obvious inconvenience, and is only accidentally detected in dissection after death. It appears to maintain its vitality for some years, but finally dies, and undergoes degradation. Only when it can be detected in such position as the interior of the eye or beneath the conjunctiva can the patient be relieved by surgical aid. Elsewhere, even if its presence is suspected, it is ordinarily beyond the reach of medical treatment. The writer a few years since, in dissecting the body of a colored man to illustrate his lectures on the muscles, found two living measles, of which one was in the diaphragm and the other in the transversalis muscle of the abdomen, but none were detected elsewhere. The parasite unquestionably gave no inconvenience to its host during life.

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Other species of Tænia which have been observed as parasitic in the human intestine are mostly of rare occurrence.

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TÆNIA CUCUMERINA, the common tape-worm of the dog, and TÆNIA ELLIPTICA, the common tape-worm of the cat, are very much alike in appearance, and are regarded by many authorities as the same species. They occur frequently in considerable numbers in these animals, living in the small intestine. They have also been occasionally found in man, especially children.

It is a comparatively delicate worm, chain-like in appearance, ranging from four inches to a foot in length. The head is provided with four suckers and a prominent rostellum armed with about sixty hooks. The neck and anterior part of the body are thread-like. The mature segments are elliptical in outline or like a melon-seed, whence the name. There is a double set of sexual organs, and a genital orifice occupies the middle of both lateral margins of the segments. The ripe segments become readily detached and creep actively in the intestine, and are either expelled with the feces or they spontaneously creep from the anus. The eggs are comparatively few and measure 0.05 mm.

Late researches appear to show that the eggs adhering to the hair about the anus or elsewhere are eaten by lice of the same animals, and within these insects undergo further development. The dog and cat, subsequently swallowing the lice, infect themselves with the mature worms. Thus also persons, especially children, from too great familiarity with these animals, directly or through their food, may likewise become infected.

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TÆNIA NANA, the Dwarf tape-worm, has been observed but once. It was discovered by Bilharz, in Egypt, in a boy who died of meningitis. It {938} is a little worm, about half an inch in length, and occurred in large numbers in the duodenum.

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TÆNIA TENELLA.--This is another small species, which has been but once observed. It is described by Cobbold, who suspects it to be derived from measles of the sheep.

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TÆNIA FLAVOPUNCTATA is also a small species, from eight to ten inches long, with ripe joints about one millimeter long and from one and a half to two millimeters broad. It is described by Weinland, and has also been but once observed. A half-dozen specimens were discharged from a healthy child, of nineteen months, in Boston, Mass.

Since the above was written the author has had the opportunity of examining some little tape-worms which he suspects to be of the same kind as the former. They occurred in the practice of T. V. Crandall in Philadelphia, and were expelled from a child of three years of age after the use of santonin. About a dozen fragments appear to have pertained to three worms, from twelve to fifteen inches in length. The head in all was lost. The anterior part of the body is thread-like, the posterior part about two and a quarter millimeters wide. The width of the joints is more than twice the length. The ripe joints are pale brown, and are remarkable for the comparative simplicity of the uterus, which is distended with brown eggs. A peculiarity of the worm is the repeated but irregular alternation of fertile with sterile joints.[1]

[Footnote 1: _Amer. Journ. of Medical Sciences_, 1884, p. 110.]

The species is probably more common than might be supposed, and from its small size, and perhaps harmless character, has generally escaped notice.

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TÆNIA MADAGASCARIENSIS.--This species, described by Davaine, is imperfectly known. Fragments of the worm have been twice observed in the Comoro Islands.

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BOTHRIOCEPHALUS LATUS.--SYNONYMS: Dibothrium latum; Tænia lata; Broad tape-worm.

This tape-worm, of another genus than the preceding, is a common parasite of man in certain localities of Europe, but has not been found as an indigenous product elsewhere. It occurs especially in Sweden and Russia, East Prussia, Poland, and West Switzerland. In the latter country it prevails to such an extent that it is reported that about one-fourth of the inhabitants of Geneva are thus infested. Among the tape-worms submitted to the writer from time to time for identification a few years ago was a large specimen of Bothriocephalus latus, but it proved to have been derived from a Swede who had arrived in this country only a few months previously.

There are many species of Bothriocephalus, which in the adult condition mainly live in fishes. The genus is distinguished from Tænia by many points, chiefly in the form and construction of the head, the form of the joints and uterus, and the position of the genital aperture, which is situated centrally on one of the broad surfaces instead of the lateral margin.

{939} The broad tape-worm is the largest of the tape-worms infesting man, a full-grown specimen reaching to twenty-five feet in length with a breadth of three-fourths of an inch, and consisting of upward of four thousand segments. It is a soft, grayish, flat, band-like worm, with head, neck, and segmented body holding the same proportions as in the other tape-worms. The head is elongated, clavate, and is provided with a long, narrow, elliptical sucker on each side. The narrower neck is short and merges into the segmented body, which gradually widens to half an inch or more. As the segments successively enlarge, they increase proportionately to a greater extent in breadth, so that their width for the most part measures from two to four times their length. A few toward the end of the series become narrower and longer than those in advance. In the ripe segments the uterus, distended with brownish eggs, forms a central rosette-like group of pouches. The genital aperture is central in the broad surface of the segments, and is always on the same or ventral side.

The broad tape-worm inhabits the small intestine, and is usually found single, but occasionally several together, and sometimes also in association with one or both the other common tape-worms. The species is also reported to be not infrequent in the dog.

Ripe portions of the broad tape-worm become detached in fragments of variable length, to be discharged with the feces. The partially-emptied appearance of the uteri in these fragments indicates the laying of the eggs previous to the expulsion of the latter. The eggs are oval, of a light-brown color, and measure about 0.07 mm. long. The shell at one pole is furnished with an operculum or lid for the escape of the embryo. This is developed subsequently to the discharge of the eggs from the intestine. If the eggs are placed in water, in the course of some months the embryos are developed and escape from the shell. The embryo is a round or oval body furnished with three pairs of spicules, as in that of the Tæniæ, but differs in possessing a ciliated envelope, by means of which it freely swims about in the water. After some days the embryo discards its envelope and creeps about in an amoeboid manner. Further than this, until recently, the fate of the embryo was unknown. Braun of St. Petersburg, after determining the presence of scolices of Bothriocephalus in the muscles, liver, and organs of generation of the pike, trout, and eel-pout, by feeding these to cats and dogs succeeded in rearing worms which differed in no respect, except in being smaller, from the Bothriocephalus latus of man. Such being the case, it becomes evident that man may ordinarily become infested with the parasite by eating raw or insufficiently cooked fishes of the kind mentioned.

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BOTHRIOCEPHALUS CORDATUS, described by Leuckart as a common species infesting the dog in Greenland, has been reported as having once been found in a woman. Böttger regards it as not distinct from Bothriocephalus latus.

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BOTHRIOCEPHALUS CRISTATUS.--This species, but once observed, is described by Davaine. It was passed by a child in Paris, and the worm was upward of nine feet in length.

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SYMPTOMS OF TAPE-WORMS.--Whichever may be the species of {940} tape-worm infesting the human intestine, the symptoms to which it gives rise are mainly of the same character, modified of course in degree by the size and number of the parasites and the susceptibilities of the patient. Clinging by means of the head to the mucous membrane of the intestine, and involved among the valvulæ conniventes and villi, the worm may extend in loose folds along the greater part of the course of the intestine or lie coiled in an elongate mass. Besides being rendered evident from time to time by the discharge of segments or fragments, the beef tape-worm especially sometimes introduces itself to the notice of its host through the segments creeping from the anus. Sometimes segments of tape-worms are vomited, especially in women; and the exhibition in this way, especially of the pork tape-worm, is to be deplored, for should segments be retained in the stomach the patient becomes further liable to be affected with measles or cysticerci.

Some persons continue infested with a tape-worm a long time without suspecting its existence and with little or no inconvenience, and perhaps first become aware of its presence by the accidental discovery of segments discharged from the bowels. Usually, however, the parasite creates more or less disturbance, and not unfrequently occasions great discomfort. The symptoms are both local and of a general nature. Itching at the extremities of the alimentary canal and various dyspeptic symptoms are common; uncomfortable sensations in the abdomen, uneasiness, fulness or emptiness, feeling of movement attributed to the worm, and colicky pains; disordered appetite, sometimes deficient, oftener craving; paleness, discoloration around the eyes, furred tongue, fetid breath, and sometimes emaciation; fulness of the forehead, dull headache, buzzing in the ears, twitching of the face, and dizziness; often uncomfortable feelings in the abdomen increased by fasting, which are temporarily relieved by taking a full meal. Certain kinds of food also at times appear to produce greater uneasiness, apparently due to more than usual disturbance of the parasite. Symptoms of a more grave character are sensations of fainting, chorea, and epileptic fits. Others of a chlorotic and hysterical character are not unfrequent, especially in women, who also may suffer more or less from uterine disorder.

All the ordinary symptoms are quickly relieved by the expulsion of the tape-worm--permanently if it is entirely removed, but temporarily, as is frequently the case, when only the greater bulk of the parasite is discharged and the head continues to remain securely attached to the intestine and ready to renew its many-segmented body. The tape-worms are capable of a wonderful amount of extension from traction without detachment; and from the delicacy of the neck and the anterior part of the body, and the action of medicine on the peristaltic motion of the intestine, the posterior part of the worm, including its great bulk, is most apt to be torn away and discharged, while the head remains. So long as this is the case, and the worm has not been poisoned or killed, the anterior portion grows, and thus the parasite is renewed and accompanied by a return of all the former symptoms. Under the appropriate treatment the evacuations of the patient should be carefully inspected, so as to satisfy both physician and patient that the parasite has been completely expelled. To properly examine the evacuations, they should be repeatedly drenched with clear water, and the sediment, after the settling {941} of the washings, must be inspected. It is only when the physician has seen the head of the parasite that he can reasonably ensure his patient a permanent cure.

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