Chapter LVIII: Front Matter (58)

TREATMENT.--To get rid of tape-worms many remedies have been employed, though comparatively few retain a reputation for positive success. Some act by powerfully operating on both bowels and worms, producing the detachment and discharge of the latter without killing them, as is often indicated in the lively movements they exhibit after their expulsion. Others poison and kill the worms, and also cause their detachment and expulsion from the bowel.

Before the administration of the appropriate medicine for tape-worms, with the object of rendering it more effective it is advisable to bring the alimentary canal into a condition which will render the parasites most vulnerable. For this purpose fasting is to be recommended for several days previously, and when food is used it should be in moderate quantity, and of such a character as to leave little residue to accumulate in the intestine. Wheat bread, the ordinary meats, milk and coffee, are best, while the usual vegetables should be avoided.

One of the most effective remedies is the oil of turpentine in the dose of one or two fluidounces, made into an emulsion with white of egg and sugar; children require about half the quantity. The large dose is less apt to produce the usual objectionable effects of that medicine than small ones. The only inconvenience caused by it is the heat of the stomach, some febrile excitement, and fulness of the head or headache lasting for one or two days. The effects are more apt to occur when the medicine does not act as a cathartic. The oil usually operates quickly, killing the worm and producing its discharge. If it does not act in the course of two or three hours, a full dose of castor oil may be given, and, if necessary to aid the action of this, enemata may be employed. To ensure the purgative action of the oil of turpentine it may be advantageously associated with the castor oil, of each a fluidounce made into an emulsion.

Another and effective remedy is the root of the male fern, Aspidium filix-mas, used in decoction or electuary. Stein of Frankfort recommends the ethereal extract as the best preparation, and prescribes it in doses of from seven to ten grammes, enclosed in half the number of gelatin capsules and administered at short intervals within half an hour. It should be taken in the morning fasting, after taking a cup of coffee, swallowing the capsules with the aid of a second cup. Half an hour after the capsules are taken a mixture of castor oil, brandy, and ginger syrup, of each fifteen grammes, should be administered. The treatment has proved all that could be desired, and the worm, including the head, is discharged altogether, rolled into a ball.

The bark of the pomegranate-root, Punica granatum, is also a powerful and efficient remedy, but often proves very disagreeable from its producing violent pains in the abdomen, with nausea and vomiting. It also generally purges, occasioning the discharge of the worm. Küchenmeister prefers it to any other medicine, given in the form of decoction prepared by macerating three ounces of the fresh bark in twelve fluidounces of water for twelve hours, and concentrating the infusion by gentle heat to one-half. He recommends it to be taken after fasting a day and the {942} administration at night of two fluidounces of castor oil. It is to be given in three or four doses within an hour. Should the medicine not purge, it should be followed by another dose of castor oil.

Recently, Feraud has recommended the tannate of pelletierin, the alkaloid of which is derived from the pomegranate-root, as the most powerful of remedies for tape-worm, the dose for an adult being one-half to three-fourths of a grain. The patient should fast a day on bread and milk, and the following morning, before rising, take an infusion of one-third of an ounce of senna. This should be followed an hour later by half the medicine diffused in a little water, and the patient should remain quiet in bed to avoid nausea and vomiting. Half an hour later the rest of the medicine is to be given, followed in another half hour by a dose of castor oil. Should there be no stool after an hour, purgative enemata may be used. In one case twelve beef tape-worms were discharged together measuring, collectively, fifty meters.

Kousso, the flower of Brayera anthelmintica, an Abyssinian herb, has been of late much employed as a remedy for tape-worms, but with many physicians of experience it has lost favor. Heller speaks of it highly, and recommends it to be taken in the morning, an hour after the patient has taken coffee. The dose is from half an ounce to an ounce, and is conveniently taken in compressed balls or disks, coated with gelatin, and swallowed at intervals in the course of an hour, aided by mouthfuls of coffee. Any disposition to vomit should be repressed, which is rendered easier by taking small mouthfuls of strong coffee or pieces of ice.

Koussin, an alcoholic preparation of kousso, is also efficient, and has the advantage over the latter that it does not occasion nausea. It has been used in the medical clinic of Munich in the dose of 30 grains, and it has been a very rare occurrence that the result was not all that could be desired.

The seeds of the common pumpkin, Cucurbita pepo, are extolled by many physicians as a remedy for tape-worms; and the writer has twice had the opportunity of observing large specimens of the beef tape-worm which were expelled after the administration of this medicine. The dose is an ounce of the seeds bruised into a paste and made into an emulsion. It should be taken in the morning, fasting, and followed in an hour or two with a full dose of castor oil.

Santonin, a principle derived from santonica, Artemisia maritima, is reported as a remedy for tape-worms, but its efficacy has also been denied. The dose is from two to four grains for an adult, and from one-quarter to one-half a grain for children over two years. It is best administered in lozenges prepared with sugar and tragacanth.

The quinia sulphate has also been recommended as an effectual remedy both in tape- and seat-worms.

As regards the prophylaxis of tape-worms, there are some important points to which we direct attention.

The evacuations of patients containing tape-worms, their segments and eggs, should not be carelessly thrown away, at least in places accessible to animals which may become infected. They should be treated with boiling water, the heat of which is sufficient to kill all animal parasites. The handling of living tape-worms and segments should be avoided, as eggs {943} which may adhere to the hands, if transferred to the mouth and swallowed, will produce infection.

Meats visibly infested with measles are not fit and should not be used as food. Raw meat should altogether be discarded as food, both for the sick and well, and all meats should be thoroughly cooked. As a rule, meat should not be used so long as it appears red or on cutting emits a bloody liquid. A large piece of meat requires long boiling or roasting for sufficient heat to penetrate to the interior to destroy any parasites that may be present. Even salted meats and hams should be cooked to ensure against parasitic infection. It is important also to avoid food prepared by uncleanly persons who may be infested with tape-worms.

As regards our domestic animals, which are the common source of the infection of man with tape-worms, they should also be protected from infection as far as possible. This is to be done by preventing them from having access to human excrement. As Heller remarks, with this object the barbarous custom of defecating in every place promiscuously should be put down with a high hand.[2]

[Footnote 2: Several years since a physician of Texas sent to the writer a piece of pork, making inquiry as to its condition, and stating that all the pigs of his vicinity were diseased and their flesh similarly affected. It contained a number of measles or larval tape-worms. On giving the information and the probable cause of the affection of the pigs, the doctor reported in return that there was not a privy in his village. Until our people are more careful with the raising of pigs, European governments will have reason for prohibiting the importation of our pork.]

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TÆNIA ECHINOCOCCUS.--SYNONYM: Hydatid tape-worm.

Larval condition: Echinococcus; E. hominis; E. veterinorum; E. granulosis; E. scolicipariens; E. altricipariens; E. hydatidosus; E. multilocularis; E. cyst; Hydatid; Hydatid cyst; Acephalocyst.

This tape-worm, in its mature state the most insignificant looking of its kind, though not strictly an intestinal worm of man, in the juvenile condition is one of his most dangerous parasites, as being the source of hydatid tumors. The adult tape-worm lives in the small intestine of the dog and wolf, in some localities often existing in these animals in thousands together. From its diminutive size it may be readily overlooked, concealed or obscured by the villi among which it is suspended to the mucous membrane. It is about a fourth of an inch in length, and consists of but four segments, of which the last alone exhibits the ripe condition. The head resembles in construction that of the pork tape-worm, being provided with four suckers and a prominent crown, with from thirty to fifty hooks arranged in a double circle. The terminal ripe segment exceeds in size all the preceding together, and before it separates from the series another is ready to take its place. The ripe eggs contain the usual six-spined embryo as in other tape-worms.

The mature worm is remarkable for the comparative shortness of its life, which, according to Siebold, is about seven weeks. Apparently to compensate for the small number of its segments, the larval form is endowed with the power of multiplying itself to a wonderful degree.

It is only in the larval condition that the hydatid tape-worm infests man, and in this state also it infests the ape, the ox and sheep and other ruminants, also the horse, hog, and indeed many other animals of the same class.

{944} If the eggs of the tape-worm are swallowed, which may readily happen by too free intimacy or association with infested dogs, the liberated embryos obtain access to the intestine. Penetrating the mucous membrane, the embryos thence may migrate to any part of the body. From the comparative frequency of hydatid tumors in the liver we may suspect they mostly enter the portal venous system and take the course of the blood-current. It is, however, probable that they migrate directly to their destination, for hydatid tumors are also frequently seated in the neighboring organs and the abdominal walls. The embryo tape-worm, once fixed in position, becomes the starting-point of a hydatid tumor.

When dogs are fed on the liver, or other parts affected with hydatid tumors, from the sheep or other animals, the scolices are liberated, and, passing into the small intestine, are there developed into the mature tape-worms.

Hydatid tumors occur in any of the organs of the body, but are more frequent in the liver than in all others together. They are common in the lungs, kidneys, spleen, omentum, and subperitoneal tissue of the abdominal walls. They are less common in the heart, brain, spinal canal, the pelvic viscera, and the bones. Mostly but a single tumor is found in the same person, but occasionally several occur together in the same or in different organs.

There are several varieties of the hydatid tumor. In man the more common form consists of a cyst or a group of cysts enclosed in a connective-tissue envelope induced by the presence of the parasite. The simple cyst is produced through the transformation of the echinococcus embryo, and the group of cysts is derived from the former by proliferation; and hence the first has been called the parent cyst, and the others the daughter cysts. These also in the same manner may produce a third series, called granddaughter cysts. The parent cyst, at first spherical, becomes modified in shape according to the space it occupies and the resistance to which it is subjected, thus assuming an oval, lobulated, or other form. It may increase in size to that of a cocoanut or larger, and may remain simple, but usually is compounded by proliferation in the production of daughter cysts. These may be few or many up to hundreds, and range from a minute size up to that of a walnut, and are spherical or modified in shape by mutual pressure or other cause. The cysts are filled with a clear watery liquid of saline taste, but without albumen.

The hydatid cysts are usually composed of an outer thick, translucent, homogeneous, laminated, glistening, highly elastic membrane, the ectocyst, and an inner thin, granular, and cellular layer, the endocyst. From the endocyst originate minute buds, which become the brood-capsules of the larval worms or scolices. These form little groups of a few to a dozen individuals suspended within the brood-capsules, but capable of eversion from them. The individual scolices, which appear to the naked eye as mere white points, have the form and construction of the head-segment of the mature Tænia echinococcus. After death or by violence they become easily detached, and then float free in the liquid containing them. In some cases the echinococcus cysts develop no scolices, in which condition they constitute acephalocysts. Occasionally the echinococcus embryo undergoes imperfect development, constituting the multilocular hydatid tumor, rarely found elsewhere than in the liver.

{945} Echinococcal tumors, especially those which have many daughter cysts, when accessible are remarkable for exhibiting a tremulous movement when grasped by the hand and quickly tapped with the finger.

Infection through the embryonic form of the Tænia echinococcus, as the source of hydatid tumors, is productive of the most disastrous consequences, and has ended in the destruction of many lives both of men and domestic animals. The parasite is not directly productive of suffering, but its effects and dangers are proportioned to the size of the tumor it occasions and the character and importance to life of the organ in which the latter is situated. With the increase of the hydatid tumor, usually of very slow growth, it encroaches upon the surrounding parts, and if these are not displaced they become disorganized and atrophied.

The liability and frequency of infection with the hydatid disease appear to be proportioned to the prevalence of intimate association with the dog. In Iceland, in which it is said every peasant owns half a dozen dogs, which share his dwelling with him, it is also reported that one-sixth of all the deaths are due to the hydatid parasite.

Ordinarily, the hydatid disease is beyond the reach of medical treatment. The mercurials and potassium iodide have been recommended, but the results are very doubtful. Apparently as an indication how little hydatid parasites may be influenced by medicine, the following incident will show: The writer once received for dissection the body of an English sailor which had been injected with zinc chloride for preservation. In the abdominal wall in the right iliac region there was a hydatid tumor the size of a fist. On examination of the tumor it was found full of daughter cysts, and these contained living scolices, though the man had been dead several days and the tissues were bleached by the zinc solution.

Favorable results in the treatment of hydatid tumors are only to be expected through surgical means when they are accessible.

As a prophylactic measure against infection the avoidance of too intimate association with dogs is especially to be recommended.

In concluding the chapter on Tænia echinococcus, as a prophylactic against this and other parasites Cobbold gives the advice that "all entozoa which are not preserved for scientific investigation or experiment should be destroyed by fire when practicable, and under no circumstances whatever should they be thrown aside as harmless refuse."

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TÆNIA ACANTHOTRIAS.

Larval condition: Cysticercus acanthotrias.

This species has been but once observed, and only in the larval condition or that of the scolex, which was first described by Weinland. About a dozen specimens were found by Jefferies Wyman of Boston in the body of a woman of Virginia who died of phthisis. They were situated in the connective tissue beneath the skin and in the muscles, except one, which was attached to the dura mater. The scolex is distinguishable from that of the other human tape-worms in possessing a triple circle of hooks. The mature form of the worm remains unknown.

{946} The Trematodes, or Fluke-worms.

The trematodes or fluke-worms, though allied to the tape-worms, differ in many important characters. In the mature condition, like the latter, they are solid worms or are devoid of a body cavity or coelum, and are with rare exceptions hermaphroditic. They are, however, never compound, but simple or consist of single individuals, and are provided with a mouth and alimentary canal, but this is closed or is without an anal aperture. They have a water vascular system, communicating with the exterior by a pore at the posterior extremity of the body. They are commonly of flat, elliptical shape, with a sucker-like mouth at the fore end, and with a second sucker situated ventrally near the middle.

The fluke-worms are remarkable for their successive transformations and course of life, and, like the tape-worms, they pass the different stages of their existence in different animals. A number of species have been described as infesting man, but most of them are, fortunately, of rare occurrence.

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DISTOMUM HEPATICUM.--SYNONYMS: Fasciola hepatica; Liver-fluke.

This species, the common liver-fluke, occasionally occurs in the human body, but is especially frequent in the sheep and other ruminating animals, as the ox, goat, and deer, and it likewise occurs in the horse, hog, and some other animals. It usually inhabits the liver, occupying the bile-ducts, but is also sometimes found in the portal and other veins and in the intestine, and more rarely in abscesses beneath the skin. It is the cause of the affection in sheep called rot, of which many thousands die annually.

The liver-fluke is a flat, tongue-shaped, brownish worm about an inch long and about half as wide. It is invested with minute scale-like spines. The head end is somewhat prolonged, and terminates in a small oral sucker, a short distance behind which is a small ventral sucker. The intestine is forked and much branched. The genital aperture is situated between the oral and ventral suckers. The commonly yellowish eggs are numerous and large, oval, and measure about 0.135 mm. long.

The common liver-fluke frequently occurs in large numbers, even hundreds, in the liver of the sheep, obstructing the bile-ducts and occasioning more or less destruction of the organ. The eggs pass off with the bile into the intestine, and are discharged with the excrement. In water the eggs are hatched, and deliver a ciliated and freely-swimming embryo. This in favorable positions, such as marshy pastures, obtains access to small fresh-water snails and penetrates to the interior of their body. Here the embryo sheds its ciliated integument and is transformed into a sporocyst. This is an elliptical pouch containing reproductive bodies, which become developed into individuals of more elongated form than the sporocyst, provided with a mouth and stomach, and named redias, or nurses. The nurse penetrates to the liver of the snail, and there develops within itself new forms called cercarias, which resemble the parent fluke-worm, but are provided with a long, powerful tail and have no apparent generative apparatus. The cercaria escapes through an aperture of the nurse, and makes its way out of the snail into the water, where it swims about actively by means of the tail, much in the manner of a tadpole. {947} The cercaria after a time fixes itself to a submerged plant, becomes encysted, shakes off its tail, and remains in a quiescent state. If in this condition, in the feeding of sheep or other animals, the tailless cercaria or incipient fluke-worm is transferred to the stomach, it makes its way to the liver, and there grows and is developed into the sexually mature worm.

Recently it has been ascertained both in England and Germany that the juvenile state of the fluke-worm is passed especially in the little fresh-water snail Lymneus truncatulus. As, however, the common liver-fluke occurs in America, while the last-named species of Lymneus does not, it is rendered probable that the juvenile condition of the parasite also occurs in other species of snails. Incidentally, the writer may here mention that he has found certain of our smallest fresh-water snails, such as Planorbis parvus, frequenting meadows in the vicinity of our rivers and creeks, swarming with nurses of several different species of fluke-worms.

Notwithstanding the frequency of the common liver-fluke in the sheep and other domestic animals, its occurrence has been rare in man, and in all the cases reported it has been few in number, either single or from two to half a dozen. In man it has been found to occupy the bile-ducts, the portal vein, and abscesses beneath the skin.

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DISTOMUM LANCEOLATUM.--SYNONYM: Smaller Liver-fluke.

This species, much smaller than the preceding, is of lanceolate form, acute behind, smooth, and about a third of an inch long. Its suckers are moderately large, and the bifurcate intestine is unbranched. It infests the liver of the sheep and ox and some other animals, and not unfrequently is found in association with the former species. It usually does not occur in such great numbers together as in the latter; from which and other circumstances, as the smaller size and smooth investment, it does not produce the same serious results. Its continuous history remains unknown, though it is probable that its course is similar to that of the common liver-fluke. Several cases are reported of its occurrence as a parasite in man.

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DISTOMUM SINENSE.--Under this head Cobbold has recently described a species somewhat larger than the D. lanceolatum. It occurs in the liver of Chinese.

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DISTOMUM CONJUNCTUM.--Another species described by Cobbold under this name, originally found in the liver of an American fox, has also been detected in man. The worm is about one-fourth of an inch long.

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SYMPTOMS.--Cases of fluke-worms in the human liver have occurred so rarely that we are not prepared to indicate with certainty what may be the nature of the peculiar symptoms. If the parasites were numerous, they would give rise to more or less obstruction of the bile-ducts, with accumulation of bile, accompanied with jaundice and other symptoms usually attendant on functional disturbance of the liver. As in sheep, they would occasion dilatation of the bile-ducts, catarrhal inflammation, incrustation with biliary matters, hyperplasia of the surrounding {948} tissues, and more or less disorganization and atrophy of the secretory structure.

TREATMENT.--As regards the treatment, we can say almost nothing. In the destructive disease of rot in sheep there are no known means to expel the parasites from the liver. If present in man, as they occur but few in number, we may hope for their spontaneous expulsion in due time without leaving any serious result. As a means of prophylaxis persons should carefully avoid salads prepared from subaquatic vegetables, like cress, which may harbor little fresh-water snails.

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DISTOMUM HETEROPHYES.--This is a small species, about half a line long, with the fore part of the body covered with minute spines, and having a large, nearly central, ventral disk. It has been but once observed, and was reported by Bilharz, in Cairo, as having been found, in the post-mortem examination of a boy, in the small intestine, in which it existed in hundreds.

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DISTOMUM CRASSUM.--This is the largest of the fluke-worms infesting man, and measures from one to three inches in length. It is elliptical, comparatively thick, and smooth. The two suckers have nearly the same relative size and position as in the D. hepaticum. It inhabits the duodenum, and has been observed a number of times infesting inhabitants of China and India.

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DISTOMUM RINGERI.--A species by this name, about half an inch long, has recently been described by Cobbold as infesting the lungs of people in Formosa and China.

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DISTOMUM OPHTHALMOBIUM.--A minute species, described under this name, has been detected several times in the human eye.

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BILHARZIA HÆMATOBIA.--SYNONYM: Distomum hæmatobium.

As a human parasite this is the most important of the fluke-worms, being the most common and dangerous. It is apparently restricted to Africa and Arabia, and is especially frequent in Egypt, Abyssinia, the Cape of Good Hope, and Natal. So far as known, it is peculiar to man and monkeys, and inhabits the veins, especially those of the portal system, and it lives on the blood.

The blood fluke-worm is remarkable among its kind in having the sexes distinct. The female is slender, cylindrical, and tapering toward the ends, looking more like an ordinary thread-worm than a fluke-worm, and is about three-fourths of an inch long. The male is about half an inch long, but wider than the female, which it partially embraces at maturity by doubling upon it laterally.

This parasite, of the same essential nature as the more ordinary fluke-worms, is most probably introduced in the juvenile condition into the stomach by drinking unfiltered standing waters, and perhaps also by eating vegetables which grow in wet places and upon which the young fluke-worms may be encysted. From the stomach the worms gain access to the portal venous system, within which they undergo development to sexual maturity. The worms, proportioned to their number, {949} occasion more or less sudden and dangerous hæmaturia. According to Bilharz, who first discovered the parasite, it also induces inflammation of the ureters, bladder, and rectum, accompanied with ulceration and incrustations and concretions in the same, due to the abundant deposit of eggs in the mucous membrane. The symptoms in the hæmaturia are obvious; all treatment fails, but the prophylaxis is evident.

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AMPHISTOMUM HOMINIS.--The genus Amphistomum is distinguished from Distomum in having the ventral disk placed at the posterior extremity of the body.

A species has been recently described by Cobbold under the above name, and is reported as having been observed several times in natives of India. It is a red worm, about the fourth of an inch long, and inhabits the cæcum and ascending colon, in which it was found in hundreds together. The mucous membrane exhibited venous congestion and was marked with numerous red spots resembling leech-bites, produced by the parasites. One of the patients died of cholera.

We have too little information as to the symptoms induced by this parasite, and of its treatment, to say anything. It is probable that calomel, turpentine, and castor oil would be appropriate remedies.

Several other fluke-worms which have been reported as having been found in the human body are generally viewed with doubt as to their genuineness. Such are the Hexathyridium pinguicola, from a tumor of the ovary; the H. venarum, said to have been found in the blood and in the sputum of hæmoptysis; and the Tetrastomum renale, said to have been found in the urine.

The Acanthocephali, or Thorn-head Worms.

The thorn-head worms in the mature condition are comparatively robust cylindrical worms, with a body-cavity or coelum, but devoid of mouth and alimentary canal. They are provided with a protrusile and retractile proboscis-like head armed with circular rows of recurved hooks, by which they firmly cling to the wall of the intestine of their host. The sexes are distinct. There are many species, which mostly in the mature state live in fishes. In the juvenile or larval condition they live in other animals, mostly crustaceans and insects. It is doubtful whether any species naturally infests man.

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ECHINORHYNCHUS GIGAS.--The great thorn-head worm is a common parasite of the hog, living in the small intestine. It is a large white worm, the female of which reaches a foot in length, while the male is about one-third the size. It is doubtful whether it occurs as a human parasite, though a worm less than the fourth of an inch found in a man in Prague has been attributed to this species.

The Nematodes, or Thread-worms.

The nematodes, or thread-worms, are slender, cylindrical, and inarticulate, and usually more or less tapering toward one or both extremities. {950} They have a distinct coelum or body-cavity, with thick muscular walls limited by a transparent elastic, chitinous integument, which is sometimes more or less distinctly and regularly transversely wrinkled. The alimentary canal extends the length of the coelum, with the mouth at the anterior extremity, and usually an anus at or near the posterior extremity. In some forms in the mature condition the intestine is atrophied and the anus absent. The sexes are distinct, and commonly the male is very much smaller than the female. The organs of generation occupy the coelum along the sides of the intestine. The female aperture is commonly situated ventrally near or in advance of the middle of the body, while the male aperture is at or in the vicinity of the anus. Mostly, the worms are oviparous, but many are viviparous. The development is direct, and usually the transformations are inconspicuous, so that the embryos mostly differ but little from the parent, except in the absence of the generative apparatus.

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OXYURIS VERMICULARIS.--SYNONYMS: Ascaris vermicularis; Seat-worm; Pin-worm; Maw-worm; Maggot-worm; Thread-worm; Ascarides.

The seat-worm is the most common intestinal parasite of man, prevails everywhere, and is peculiar to him. It is a lively, wriggling creature which inhabits the small and large intestines and feeds on their contents. It frequently occurs in large numbers together, and in such cases incessantly makes its appearance, associated with multitudes of eggs, in the evacuations.

The female, which is ordinarily seen alone in the greatest abundance, is a white cylindrical worm tapering toward both extremities. The head end is thickened, and is provided with three prominent labial papillæ enclosing the mouth. The posterior end extends from the anal aperture in a long and straight, narrow, conical, sharp-pointed tail. The double uterine tube, distended with eggs, terminates in a vagina, the external aperture of which is situated ventrally near the anterior third of the body. The smaller male hardly tapers behind, but is incurved and ends in a short, blunt, conical tail. The penis is a single chitinous spicule, the end of which is usually seen projecting from the cloacal aperture.

The young seat-worms, in various degrees of growth and development, and the mature males are chiefly to be met in the lower portion of the small intestine, while the pregnant and mature females chiefly occupy the cæcum.

The seat-worm is exceedingly prolific, it being estimated that a single ripe female contains from 10,000 to 12,000 eggs, and these, it is suspected, may be renewed several times before her functions become exhausted. From time to time the ripe females proceed along the large intestine to the rectum, in which position they lay most of their eggs. These are discharged, together with many of the worms, in the feces.

The eggs are ovoid in shape and about 0.05 mm. long. After they are laid under favorable conditions the embryos are rapidly developed. Left in water, they soon die.

The investigations of the helminthologists of the day make it appear that it is necessary that the eggs of the seat-worm should be swallowed {951} and pass through the stomach, in which the embryos are freed, before they can undergo development to sexual maturity. Moreover, observations go to show that infection may, and probably ordinarily does, occur from eggs scratched from the anus and conveyed to the mouth directly or by being applied to food from uncleanly hands. It is evident that itching of the anus, induced by the presence of the parasites in the rectum, often accompanied by itching of the nose and lips, may lead to alternate scratching of the parts and the transference of eggs from one to the other. Thus, too, uncleanly nurses who may be infested with seat-worms after scratching may handle food and infest children under their charge. Children are commonly more liable to the parasites than others, no doubt from the circumstance that they are less capable of avoiding the conditions favorable to infection. Seat-worms prevail in all conditions of society, but their prevalence is largely proportioned to the more or less uncleanly habits. Persons sleeping with others infested are liable to infection, especially if they are uncleanly and in the habit of eating in bed. Obvious hints to avoid the parasites are obtained by regarding the statements thus given.

SYMPTOMS.--The presence of a few seat-worms is usually attended with no obvious inconvenience, and they may remain unnoticed unless accidentally observed in the evacuations. The symptoms occasioned by them are in great measure proportioned to their quantity and the susceptibility of the patient. The most prominent symptom is excessive itching of the anus; often trifling or even absent during the day, it becomes very annoying and distressing in the evening or during the night. This periodic change appears to be due to the movement of the worms to the rectum, apparently induced by the position and repose of the patient and the increased warmth of the body in bed. Under these circumstances the patient attempts to relieve the incessant itching by scratching, and often by boring with the finger in the anus. In this way eggs become adherent to the finger-nails, under which they have been repeatedly detected, and may thus be inadvertently transferred to the mouth. Occasionally, some of the worms wander from the anus, and in women may thence penetrate into the vulva. The itching of the anus may induce more or less sexual irritation, which in the young may further lead to onanism and its attendant evils. Other symptoms of the presence of the parasites are itching of the nose and lips, restlessness in sleep, grinding of the teeth, startings, twitchings, and general nervous disturbance. When the worms are very numerous they may produce intestinal catarrh, with discharges of mucus, pain, and diarrhoea. In children especially they may give rise to more serious nervous symptoms, as epileptic fits and chorea.

TREATMENT.--Generally, persons are readily relieved of seat-worms. Epsom salt alone or with senna as a purgative, repeated once or twice, often answers to completely expel them. Castor oil, also alone or with a few drops of the oil of turpentine or of wormseed, is also an effectual remedy. The tincture of aloes, in the dose of from half a fluidounce to two fluidounces, once or twice repeated, the writer has found to fully answer the purpose. Besides the purgatives, medicated suppositories, in obstinate cases injections of olive oil, and enemata of a solution of castile soap introduced by means of an elastic tube, so as to wash out the entire length of the large intestine, may be employed.

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{952} ASCARIS LUMBRICOIDES.--SYNONYMS: Round-worm; Long round-worm; Maw-worm; Lumbricus.

The round-worm is the largest of the nematodes which ordinarily infest man, and is second only in frequency to the seat-worm. It is a well-known parasite, and prevails everywhere in all conditions of society. It is less lively in its movements than the seat-worm, and is remarkable for possessing a peculiar disagreeable odor, which is independent of the medium in which it lives. It inhabits the small intestine and feeds on the contents. It also infests the hog and the ox.

The round-worm is cylindrical, reddish or brownish, and tapering toward both extremities. The head end terminates in three prominent labial papillæ surrounding the mouth, and the tail end is short and conical. The female, as commonly seen, ranges from six inches to a foot in length, and is about a fourth of an inch in thickness. The ovarian tubes are long, thread-like, and tortuous, and, with the shorter, nearly straight, and wider uterine tubes, contain many millions of eggs. The genital aperture is situated ventrally near the anterior third of the body. The male is about half the size of the female, but is capable of considerable extension, and the tail end is incurved. The penis consists of a pair of slender, clavate, chitinous spicules, the ends of which protrude from the cloacal aperture at the root of the tail.

The round-worm is exceedingly prolific, it being estimated that the genital tubes of a large mature female contain the enormous number of 60,000,000 of eggs. The ripe eggs are laid in the intestine, and are discharged with the evacuations in great numbers, and often in considerable masses together. They are oval, about 0.05 mm. in length, and are provided with a thick shell and an additional tuberculate albuminoid envelope, usually colored by the intestinal contents.

The eggs of the round-worm after being expelled from the body are very tenacious of life, and under ordinary favorable circumstances they may remain in a condition capable of development for several years. Experiments have shown that they have great power in resisting the destructive influences of heat and cold, dryness, and the agencies of decomposition. In water and moist earth they have been retained alive for a year or two. When ripe eggs are placed in water the development of the embryo is observed to proceed very slowly, and is only completed after five or six months. The embryo while still contained within the egg sheds its skin and becomes provided with a tooth-like spine to the head end. The smallest examples of reputed round-worms found in the human intestine measured only about a line in length.

The further history of the round-worm is unknown, nor has it yet been positively ascertained in what manner man becomes infected with the parasite. Repeated experiments, not only on the hog and other animals, but on man himself, go to show that he is not directly infected by swallowing the recently-laid ripe eggs. It is rendered probable that the eggs are swallowed by some common but yet unknown minute aquatic animal, within which the embryo may undergo further development, and in this condition may be swallowed by man in drinking-water. In confirmation of the view that man becomes infected in the latter way, Davaine remarks that the "people of Paris, who drink only filtered {953} water, are rarely infected with the round-worm, which is otherwise the case in the rural districts of France."

The round-worm is most prevalent in warm climates, and especially among the less-civilized peoples. The better classes among the more enlightened nations suffer comparatively little from the parasite, and it is the lower classes, especially the ill-fed and uncleanly, who are most afflicted. It is exceedingly frequent in the Orient, in Africa, the West Indies, and Brazil.

Most commonly, only a few round-worms--one, two, three, up to a dozen--occur together in the same person, but they often occur in considerable number, even to several hundreds. Not unfrequently they are found in association with seat-worms. They are more frequent and usually occur in greater abundance in children, perhaps in a measure due to the circumstance that they are less able to discriminate the conditions favorable to infection and avoided on other grounds by adults.

The natural and ordinary habitation of the round-worm is the small intestine, especially the jejunum, and it commonly only occurs in the large intestine, mostly dead, on the way to be discharged with the evacuations. Under disturbing circumstances, as the character of certain irritating food, the parasite is disposed to become restless and wander from its usual position. Not unfrequently it enters the stomach, and thence may ascend to the mouth or nose, and perhaps the first intimation of the presence of such an unwelcome guest is in its expulsion from the mouth. From the pharynx the worm may enter the larynx and trachea, or advance farther into the air-passages, giving rise to the usual symptoms of foreign bodies in these parts. Occasionally the parasite forces its way through the bile-ducts into the liver and gall-bladder, creating disturbance in those organs proportioned to the number and size of the worms and the extent of their progress. In the liver it may occasion inflammation and the formation of an abscess attended with all the usual symptoms of hepatitis. It has been reported that it may penetrate the intestinal wall and enter the peritoneal cavity, but it is generally regarded as doubtful whether the worm can do so in a healthy state of the intestine, but only where there may be ulceration or other similar condition.

SYMPTOMS.--The symptoms indicating the presence of the round-worm in the intestine vary with its numbers and with the age and susceptibility of the patient. In general, the presence of one or two worms is unattended with any marked disturbance, and is mostly unsuspected until the parasite is accidentally seen in the discharges. The ordinary symptoms are disordered appetite (usually increased), flatulence, hiccough, foul breath, dyspepsia, abdominal pains, itching at the extremities of the alimentary canal, furred tongue, darkening of the eyelids, and emaciation. The nervous symptoms are restlessness in sleep, unpleasant dreams, starting in fright, grating of the teeth, and muscular twitchings. In more aggravated cases, especially in children, epileptic fits may occur. If the parasites are numerous, they produce diarrhoea with copious mucus discharges, and may induce enteritis with all its attendant symptoms. When the worms wander into the stomach, they induce colic, nausea, retching, and vomiting, all of which disappear with the expulsion of the parasites.

TREATMENT.--The remedies employed for seat-worms often serve to {954} expel the round-worm, and not unfrequently the two are discharged together. Wormseed, or the seed of Chenopodium anthelminticum, has been a favorite remedy for the round-worm, especially in children. The dose in these cases is one or two scruples of the powdered seeds in electuary with syrup or molasses, administered in the morning before breakfast and at bedtime for three or four days. It should be followed by calomel or other brisk cathartic. The volatile oil, in the dose of from five to ten drops in emulsion, may be used in the same manner.

A much-extolled remedy to destroy and get rid of the round-worm is santonin, given in doses of from one-third to one and a half grains three or four times a day, the larger dose being used only for adults. It should be followed by a purgative, for which a dose of castor oil answers a good purpose.

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ASCARIS MYSTAX, the common round-worm of the cat and dog, has been reported as occasionally infesting man. It resembles the former species, but is much smaller, commonly from one to four inches in length, and has the head end furnished with a pair of lateral narrow, wing-like expansions of the integument. It inhabits the small intestine, and when present in man would no doubt induce symptoms like those of the ordinary round-worms which infest him.

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TRIOCEPHALUS DISPAR.--SYNONYMS: Long thread-worm; Whip-worm.

The long thread-worm is a not unfrequent intestinal parasite of man, though rarely observed unless specially sought, as it ordinarily gives rise to little or no disturbance. It is common in England, Southern Europe, and the Orient. Davaine reports that half the cases of persons investigated in Paris were infested with it; it also occurs in this country. It inhabits the lower end of the ileum, the cæcum, and vermiform appendix, and feeds on the intestinal contents. It commonly occurs in small numbers, two or three to a dozen, occasions no evident inconvenience, and is rarely discharged with the evacuations.

The long thread-worm is yellowish-white and cylindrical, with the anterior half or more of the body attenuated in a hair-like manner. The female reaches about two inches in length, has the tail end conical, and the anus subterminal. The male is about two-thirds the length of the former, has the thicker portion of the body enrolled, and the tail end blunt. The eggs are laid in the intestine and discharged with the feces. The subsequent history of the parasite and its mode of infecting man remain unknown.

Only in cases where long thread-worms are numerous do they give rise to trouble. According to Leuckart, Pascal gives as constant symptoms of the presence of large numbers of the parasite, headache, redness of the face, prominence of the eyes, small, irregular, and intermittent pulse, and pains in the lower part of the abdomen.

The usual remedies addressed to the seat-worm and round-worm will most probably be equally applicable to the long thread-worm.

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LEPTODERA STERCORALIS.--SYNONYMS: Anguillula stercoralis; Rhabditis stercoralis.

{955} This is a minute nematode worm recently observed infesting French soldiers in Cochin China. It is about half a line in length, and inhabits the small and large intestine, and also penetrates into the biliary and pancreatic ducts. It occurs in myriads and occasions diarrhoea and dysentery. Another species, Leptodera intestinalis, nearly three times as large, has been noticed in smaller number associated with the former. The eggs of these worms are laid in the intestines, and both together are discharged in multitudes with the feces. They are probably introduced into man by drinking stagnant water, and undergo complete development after passing through the stomach.

It is probable that the remedies employed in the treatment of the familiar seat-worms and round-worms would be equally efficacious in the expulsion of these parasites.

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ANCHYLOSTOMUM DUODENALE.--SYNONYMS: Strongylus duodenalis; Dochmius duodenalis; Sclerostoma duodenale.

This intestinal parasite, first noticed in Milan by Dubini in 1838, is of more dangerous character than any of the nematode worms previously described. In Europe, besides Italy, it was frequently observed among the workmen of the St. Gothard tunnel. It is exceedingly common in Egypt, and Bilharz found it in nearly all his post-mortem examinations of bodies. It probably prevails to a considerable extent in most tropical countries, including the East and West Indies and Brazil. There is also reason to suspect, from the nature of the affection it induces, that it may exist in the Southern States.

The Anchylostomum is a red, cylindrical worm, with the anterior extremity tapering and recurved. The head end, somewhat enlarged, encloses a capacious oral capsule armed with strong hook-like teeth. The caudal extremity of the female ends in a conical point, and the genital aperture is situated behind the middle of the body. The caudal extremity of the male ends in a trilobate pouch, within which projects the bispiculate penis. The female is from five lines to three-fourths of an inch long; the male is about half the size. The eggs are oval and measure 0.05 mm. long.

The worm inhabits the small intestine, especially the duodenum and jejunum, clinging tenaciously to the lining membrane by means of the armed mouth. It penetrates the mucous membrane to the submucous coat, from which it sucks the blood that forms its food. In the position of its attachment it gives rise to little ecchymoses. It often occurs in large numbers, even to hundreds and thousands. The eggs are laid in the intestine and are discharged with the evacuations. Externally, in water, the embryo undergoes development within the egg, and then escapes to lead for some time an independent existence. Subsequently, it is most probable that the worm obtains access to the human stomach by drinking standing water, and completes its development in the intestine.

The Anchylostomum proves to be a prolific source of wasting diseases in tropical countries, and is pernicious to an extent proportioned to the numbers infesting the intestine. By depriving the body of blood it produces a greater or less degree of anæmia. The affection begins very insidiously, and the general nutrition of the body may not be visibly disturbed {956} until a late period. In moderate cases the disease is indicated by general paleness of the skin and mucous membranes, fatigue on slight exertion, and a tendency to palpitations and quickened pulse. In more severe cases there is constantly increasing debility, with increase of paleness, indisposition to exertion, excessive sleepiness, and feeling of coldness. Dyspeptic symptoms sometimes appear, and loss of appetite may alternate with ravenous hunger. Accompanying this there is often a disposition to eat innutritious articles, as coal, clay, wool, etc. Feeling of weight and oppression in the epigastrium and abdominal pains are frequent. In the advance of the affection shortness of breath appears, increased on exertion to violent dyspnoea. Emaciation becomes obvious in the later stage of the disease. In the worst cases the symptoms increase in severity, the patient becomes dropsical, is attacked with profuse diarrhoea and vomiting, and finally dies.

The severity of the affection is proportioned to the number of parasites present and the quantity of blood they consume and cause to be lost. Bad cases may end fatally in a few weeks, but generally the disease lasts for months, and where the patient is provided with abundance of good food it may continue for years.

The prognosis of the disease is rather unfavorable; if, however, the nature of the affection is ascertained before it has greatly exhausted the patient, and the parasites can be expelled, the result should be favorable.

We have thus far obtained but little information as to the best treatment for Anchylostomum. Calomel and turpentine have been recommended, and, as these are most powerful vermicides, we have reason to believe they would prove most effectual remedies.

In regard to the prophylaxis for Anchylostomum--and we may add in general for all parasites which gain entrance to man through drinking-water--all stagnant or standing waters should be filtered, so as to remove any source of infection, whether by eggs or free embryos of parasites or of larval forms existing within minute aquatic animals which serve as intermediate hosts to parasites. Standing waters, such as those of puddles, ditches, marshes, and ponds, more or less swarm with minute animals, all of which may be entirely removed by filtration. Even the water of cisterns and wells, if supplied from the free surface of the country, may not be free from minute animals, and especially eggs, and therefore requires filtration to be safe. Only spring and freely-running water of rivers and creeks and of lakes is commonly free from microscopic animals and their eggs, and therefore devoid of all danger in these respects.

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STRONGYLUS LONGEVAGINATUS; S. bronchialis.--This nematode has been only once satisfactorily observed. Many occurred in the lungs of a boy in Germany, but the real cause of his death was not stated. The female worm is about an inch long, the male about five-eighths of an inch.

Certain worms previously discovered in the bronchial glands of a case of phthisis, and described under the name of Hamularia lymphatica, are regarded by Cobbold as the same with the former; but the descriptions of the two render this improbable. Treutler's drawing of Hamularia, as copied by Leuckart, looks like an Ascaris upside down.

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{957} EUSTRONGYLUS GIGAS; Strongylus gigas; Palisade-worm; Kidney-worm.--This worm, recorded in the catalogue of human parasites, is doubtful as such. Pertaining to the same family as Anchylostomum, as the common name indicates its usual habitation is the kidney. It is the largest of the nematodes, and is a long, cylindrical red worm, slightly tapering, and blunt at the ends. The mouth is enclosed by six rounded labial papillæ. The caudal extremity of the male ends in an inverted cup-like pouch, from which the penal spiculum protrudes. The female commonly ranges from one to three feet in length and from a fourth to nearly half an inch in thickness. The male ranges from six inches to a foot in length and from one to three lines in thickness.

The mature parasite is common in many fish-eating mammals, from which it is inferred that fishes are the intermediate host for the juvenile condition of the worm. It is frequent in the wolf, dog, mink, weasel, raccoon, otter, and seal. It also occurs in the hog, and is reported to have occurred in the horse, ox, and man. Usually it is solitary, and occupies one of the kidneys coiled upon itself. Under its influence the kidney is atrophied and reduced to the condition of a capsule of connective tissue, often containing bony spicules. It feeds on blood and on the purulent matter resulting from the inflammation it produces. The worm is occasionally found in other positions, as the mesentery, the abdominal cavity, the intestine, liver, urinary bladder, and lungs, but perhaps in most of these cases has been derived from its usual habitation. In this country the writer has repeatedly observed the kidney-worm in the mink, the dog, and the wolf. In one instance in the former animal he found a female and a male associated together in one kidney, which was reduced to the condition of a fibrous capsule containing in its wall a large radiated plate of bone.

The cases on record of the occurrence of this formidable parasite in man are of very early date, and are mostly doubtful as to the authentic nature of the worm, and are all unsatisfactory as to the attendant phenomena.

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