[840] Lohr, _Zeitschr. f. Heilk._, xxvi.
[841] Bruns, Liefmann and Meckel, _Münch. med. Wochenschr._, 1905.
Infection in human beings takes place by the mouth, if uncleansed
vegetables are eaten--in Japan especially, where human fæces are
used--and articles of food are not sufficiently carefully cleaned
(Inouye[842]), or from putting food into the mouth with dirty hands.
Looss[843] does not think that drinking water is dangerous as a rule,
for the larvæ sink to the bottom in standing water, and are only
brought to the top by shaking. Looss has done most valuable service by
discovering that infection can arise also through the skin. During the
last few years so many authors have confirmed this at first doubted
source of infection, that one must accept this source of infection
now, even though it is undecided which mode of infection is the
more prevalent, by the mouth or through the skin. Some authors have
described the changes induced in the skin by the penetration of the
larvæ; for instance, Looss and Schaudinn,[844] itching papules in their
own skin, and Dieminger[845] a skin affection in the Graf Schwerin mine
which was called the “Schweriner itch,” and a skin affection not unlike
scabies in the tea plantations of Assam and South America; pani-ghao
(water itch) (Dubreuilh[846]); the penetration of the larvæ through
the skin also explains the frequent appearance of boils and itching
purulent eczema in miners in infected pits (Goldmann[847]).
[842] Inouye, _Arch. f. Verdauungs Krankh._, 1905, xi.
[843] Looss, “Handb. f. Tropenkrankh.,” v. Mense, i, p. 129.
[844] Schaudinn, _Deutsch. med. Wochenschr._, 1904.
[845] Dieminger, _Klin. Jahrb._, 1905, xiv.
[846] Dubreuilh, _La Presse méd._, 1905, xxx.
[847] Goldmann, _Wien. med. Presse_, 1905, ii.
The absolute diagnosis of ancylostomiasis depends on the detection of
the ancylostome eggs in the fæces, and presents no difficulties.
Prophylaxis is of the greatest importance, especially to miners. The
spread of ancylostomiasis seems to depend only on fæces deposited in
damp places, so that on the one hand the deposition of fæces must
be prevented, and on the other the fæces must be rendered as far as
possible harmless; in addition, there is the individual prophylaxis.
General prophylaxis requires:--
(1) Examination immediately for ancylostomes of miners seeking work and
of those newly taken on five to six weeks after.
(2) Indentured workers who are infected with worms are not allowed to
work underground until a medical certificate in writing is brought to
the effect that they are no more infected with eggs (the same procedure
applies to workmen in brick kilns) (Goldmann[848]).
[848] _Ibid._, “Die Hygiene des Bergmannes.” Halle: W. Knapp, 1903.
(3) Indentured workers infected with worms must submit themselves to
the prescribed treatment, and after its completion further submit their
stools to three examinations at intervals of about four weeks.`
(4) Special supervision of miners and brick-makers coming from the
Italian frontier.
(5) Workmen must be given instructions, both by word of mouth and in
writing in their mother tongue, as to the infectivity and danger of
ancylostomiasis both to themselves and others.
(6) Orders are to be given as to washing, baths, and changing of
clothes at the end of the work.
(7) During the hours of working in the pits, taking of food is strictly
forbidden without thorough and entire washing.
(8) All privies must be so arranged that the vessels used for the
reception of the excreta must not leak, must be protected by a cover,
and easily transportable. The emptying of these vessels must be carried
out in specially constructed impenetrable pits.
(9) Defæcation in any other place than a privy is forbidden (alike for
miners and brick-makers).
(10) The manure of horses used in the mines is to be regularly
removed; possibly infection takes place in this way also. [This is
impossible.--J. W. W. S.]
How far it is possible to disinfect a mine already severely infected is
a matter of question; Tenholt,[849] Goldmann,[850] and Dieminger[851]
recommend washing out with freshly prepared lime water with the
addition of caustic soda; Calmette[852] and Manouriez[853] spraying
with salt water. Theoretically spraying with hot water or steam
should be done every now and again for the destruction of the larvæ
(Looss[854]). Personal prophylaxis is partially included in the general
prophylaxis in so far as it is a case of oral infection, but something
more can be done for the individual to avert the danger of cutaneous
infection. According to Manson[855] it is advisable in the tropics to
cover the naked hands and feet with green Barbados tar, and the tarred
parts thickly with flour; Fabre[856] recommends that miners who might
come in contact with infected water should anoint the unprotected parts
(hands and feet), as then the larvæ cannot penetrate the skin; this
last procedure can easily be carried out on account of its simplicity
and cheapness.
[849] Tenholt, _Münch. med. Wochenschr._, 1905.
[850] Goldmann, _Wien. med. Wochenschr._, 1905, x.
[851] Dieminger, _loc. cit._
[852] Calmette, _Acad. de Méd._, July 25, 1905.
[853] Manouriez, _Bull. de. l’Acad. de Méd._, 1905.
[854] Looss, _Zeitschr. f. klin. Med._, 1905, lviii.
[855] Manson, _Brit. Med. Journ._, November 5, 1900.
[856] Fabre, _Progrès méd._, 1905.
Among the usual remedies for the expulsion of ancylostomes thymol
certainly comes first, introduced by Bozzolo[857] and since used
by many other authors, partly with good and partly with less good
results. The day before the beginning of treatment one should
endeavour to procure a thorough evacuation of the bowels by means of
calomel (Lutz,[858] Grünberger,[859] Smith[860]) or cascara sagrada
(Mann[861]), only fluid food should be taken the evening before, and
on the day of treatment thymol is given in a quantity of 6, 8, 10 or
15 grm., in single doses of 2 grm. with one or two hours’ interval,
and some hours after an aperient. As a rule, one day of this treatment
is not enough. (Prowe[862]), but one is compelled to repeat it on two
consecutive days, or even oftener, with subsequent intervals of many
days. Thymol is either given in wafers, gelatine capsules or mixed with
sugar. Caution should be used in giving brandy at the same time or[sic]
bodies which dissolve thymol (oil, fat) and thereby considerably favour
its absorption. It has been shown in many cases from toxic phenomena
that thymol is by no means an indifferent drug; violent burning in the
stomach and alimentary canal, lowering of the temperature, shortness
of breath and feeble pulse, giddiness, delirium and fainting have
all been observed. Sandwith[863] and Thornhill,[864] as well as
Leichtenstern,[865] even record cases of death after the use of thymol;
4 grm. thymol caused severe symptoms of poisoning in Grünberger’s[866]
case. The black colour of the urine (thymoluria) which so often sets
in after the first dose is quite harmless, and is no contra-indication
to the continuance of the cure. Now and again there are traces of
albumin in the urine, but it is very seldom there is any severe acute
inflammation of the kidneys. Thymol is contra-indicated in advanced
old age and in debility, also in cases with a tendency to vomiting, in
gastritis, dysentery, heart or kidney affections.
[857] Bozzolo, _Giorn. del R. Acad. d. Med. di Torino_, 1881.
[858] Lutz, _Centralbl. f. Bakt._
[859] Grünberger, _Wien. med. Wochenschr._, 1902, lii.
[860] Smith, _Amer. Journ. Med. Sci._, 1903.
[861] Mann, _Deutsch. Arch. f. klin. Med._, lxxiv.
[862] Prowe, _Virch. Arch._, clviii.
[863] Sandwith, quoted by Looss.
[864] Thornhill, _ibid._
[865] Leichtenstern, _Deutsch. med. Wochenschr._, 1887.
[866] Grünberger, _loc. cit._
The combination recommended by Goldmann[867] under the name of
taeniol, already mentioned under the treatment of tapeworms, and which
consists of thymol, sebirol and salicylate, appears also to render
good service in the treatment of ancylostomiasis (Goldmann[868] and
Liermberger[869]).
[867] Goldmann, _Ges. f. innere Med. in Wien_, March 8, 1906.
[868] Goldmann, _Wien. med. Wochenschr._, 1905, x.
[869] Liermberger, _Berl. klin. Wochenschr._, 1905.
A carbonate of thymol, thymotal, from which thymol separates off in the
intestine, is given three to four times a day, in doses of 3 grm. per
diem (children up to 1·0 grm.) on four consecutive days, and at the end
of the treatment a purge (Pool,[870] Bauer[871]); Leonardi[872] speaks
well of thymol essence (4·0 c.c. per diem) in an emulsion with plenty
of water.
[870] Pool, _Med. Woche_, 1901.
[871] Bauer, _Wien. klin. Wochenschr._, 1904.
[872] Leonardi, _Gaz. d. Osp._, 1904.
The next drug for the expulsion of ancylostomes is extractum filicis
maris, which is to be employed as in tapeworm treatment, but has not
always had the desired result, whilst in such cases as resist the fern
extract, thymol attains the desired effect (Mann[873]), whilst the
reverse is frequently observed (Grünberger[874]). Nagel[875] prescribes
extr. fil. 8 to 10 grm., chloroform 10 to 15 drops, syr. sennæ 16 grm.;
before taking, the glass must be placed in hot water, otherwise the
contents will not pour freely. Zinn[876] prefers extract. filicis
maris (freshly prepared) to all other drugs. Warburg[877] considers
the treatment with extr. fil. to be all the more certain the more
thoroughly the preliminary treatment is carried out. Filmaron
0·7 grm., thymol 5·0 grm., chloroform 1·5 grm., ol. ricini 20·0 grm.
gave good results after being given two to three times (Nagel[878]).
Opinions are divided as to the combination of thymol and extractum
filicis maris (Hynek,[879] Stockman,[880] Boycott and Haldane,[881]
Adams[882]). As regards other remedies, eucalyptus oil is well spoken
of by Philips[883] and Hermann[884]: ol. eucalypti 2·0 grm., chloroform
3·0 grm., ol. ricini 30·0 grm., to be taken at one time or in three
separate doses in the morning (on the previous evening a saline
purgative). Neumann[885] recommends podophyllin, to be taken twice
on three consecutive days in doses of 0·035 grm. Podophyllin appears
to produce quite a peculiar condition of the intestinal mucosa which
is very prejudicial to the Ancylostoma adhering to it. Bentley[886]
regards β-naphthol as the best drug; after previous examination of the
bowels he gives it two or three times at two-hourly intervals, in doses
up to 1·0 grm. (_Vide_ also the Appendix, p. 754, for other drugs.) For
the treatment of the anæmia, which often persists very obstinately,
good and abundant food, iron and arsenic preparations, Levico water
(Goldmann,[887] Liermberger[888]) are suitable.
[873] Mann, _loc. cit._
[874] Grünberger, _loc. cit._
[875] Nagel, _Deutsch. med. Wochenschr._, 1903.
[876] Zinn, “Therap. der Gegenwart.,” 1903.
[877] Warburg, _Münch. med. Wochenschr._, 1904.
[878] Nagel, _loc. cit._
[879] Hynek, _Sbornik Kliniky_, v.
[880] Stockman, _Brit. Med. Journ._, 1904.
[881] Boycott and Haldane, _Journ. of Hyg._, ix.
[882] Adams, _Arch. of Pediat._, 1901.
[883] Philips, _Lancet_, 1906.
[884] Hermann, _La méd. moderne_, 1905.
[885] Neumann, _Deutsch. med. Wochenschr._, 1904.
[886] Bentley, _Indian Med. Gaz._, 1904.
[887] Goldmann, _Deutsch. Aerzte-Zeitg._, 1903.
[888] Liermberger, _loc. cit._
*Ascaris lumbricoides* (Ascariasis).
_Ascaris lumbricoides_ is one of the most frequent parasites that occur
in man, both in adults as well as in children; as a rule, indeed, it
most frequently infects children of medium age. The normal situation
is the small intestine; this, however, is frequently left, and the
Ascarides travel into the stomach, œsophagus, pharynx, bronchi, the
nasal cavities and still other regions. It is a peculiarity of the
Ascarides that they are prone to glide into narrow canals; for example,
Clason[889] records that in the case of an idiot whose custom it
was to swallow glass beads, the Ascarides showed a predilection for
sticking in the beads and were passed in the fæces. The disturbances
which Ascarides occasion in the intestine itself vary; isolated species
do not give rise to any symptoms at all, whereas a large number may
eventually give rise to severe local symptoms, or those of a toxic or
reflex nature which have been discussed in the General Section.
[889] Clason, _see_ Seifert, _Deutsch. med. Zeitg._, 1885.
Among the local symptoms are the following: loss of appetite, excessive
appetite, perverted sense of taste, fœtid breath, sensitiveness to
pressure over the abdomen, colicky pains and irregularity of the
bowels. The appearance and state of health suffer; the patients,
children in especial frequency, become remarkably pale; their
complexions undergo rapid change, and rings of grey or bluish-brown
are seen about the eyes. Children may become so reduced by this rare
condition, enteritis verminosa, due to Ascarides in large numbers,
that suspicion of the existence of intestinal tuberculosis arises.
Emaciation to a skeleton, excessive meteorism, and evacuations of thin
gruel-like stools, sometimes blood-stained, are observed in these
cases. Even in the case of adults, chronic uncontrollable vomiting
with severe inanition due to the Ascarides has been observed. When the
Ascarides escape spontaneously _per anum_, they frequently cause an
exceedingly troublesome irritation in the anal region (pruritus ani).
The most disagreeable symptoms and those most dangerous to life arise
from the migrations of Ascarides when they invade the bile-ducts;
no inconsiderable number of cases of this kind are recorded in
the literature (summarized, up to the year 1901, in Sick’s[890]
Dissertation). Penetration _post mortem_ (or shortly before death) of
the worms into the bile-ducts cannot be considered as a rarity; the
laxity of the muscular orifices easily allows of this invasion also
in other directions on the part of the parasite in its escape from
the body of its dead host. The occurrence of the worm in the biliary
passages in the living is to be regarded as still less frequent, but
nevertheless often enough according to the records in literature.
Sick[891] was able to collect as many as sixty-one such cases, to which
he added two further fresh cases from the Tübingen clinic, that is,
from the material provided by his father. In the year 1891 Borger[892]
collected fifty-nine cases relating to the invasion by _Ascaridæ_ of
the bile-ducts and passages, and Dauernheim’s[893] Dissertation treats
of this question as well. A further case of Ascaris in the ductus
choledochus (choledochotomy) is recorded by Neugebauer.[894] In the
case of Schupper[895] (woman, aged 52), all the biliary passages were
distended and filled with fourteen living _Ascaridæ_ (perhaps as they
were living they had not led to a septic infection of the biliary
passages); in the case communicated by Schiller,[896] an Ascaris
had gained access to the biliary passages after an operation for
cholelithiasis (with distension of the gall-bladder and formation of a
fistula); it had kept itself alive here eighteen days and was extracted
from the fistulous opening. Epstein[897] confirms the correctness
of the explanation of the mark of strangulation in an Ascaris in
Mertens’[898] case (in a woman, aged 30, there was first icterus,
later ascites, anasarca, swelling of the liver, then the discharge of
two dead _Ascaridæ_, one of which exhibited a constriction somewhat
behind its centre; after that there was rapid improvement in all the
symptoms); in his case there was icterus in consequence of closure
of the ductus choledochus by an Ascaris. After the discharge of the
worm the symptoms persisted; one of the _Ascaridæ_ had a typical
strangulation mark. From the observation recorded by Vierordt[899]
it follows that, without doubt, mature females can penetrate into
the liver and there deposit eggs; in addition, that such eggs appear
exceptionally to undergo segmentation. A unique feature in this case
consisted in the exclusive discharge of immature worms almost regularly
throughout an interval of nine weeks; this cannot be explained from our
present knowledge of the biology and pathology of the _Ascaridæ_. These
worms clearly make their way from the intestine outwards, through the
opening into the duodenum of the common bile-duct, and unquestionably
the fully developed Ascarides, with the aid of their conical head end,
are enabled gradually to penetrate the wall of the ductus choledochus
(Quincke[900]), and gain access to the gall-bladder, the hepatic duct
and its branches.
[890] Sick, “Diss. Tübingen,” 1901.
[891] Sick, _ibid._, 1901.
[892] Borger, “Diss. München,” 1891.
[893] Dauernheim, “Diss. Giessen,” 1900.
[894] Neugebauer, _Arch. f. klin. Chir._, 1903, lxx.
[895] Schupper, _Gaz. d. Osp._, 1904, xxxiii.
[896] Schiller, _Beitr. zur klin. Chir._, 1902, xxxiv.
[897] Epstein, _Deutsch. Arch. f. klin. Med._, 1904, lxxxi.
[898] Mertens, _Deutsch. med. Wochenschr._, 1898, xxiii.
[899] Vierordt, Volkmann’s _Samml. klin. Vortr._, No. 375.
[900] Quincke, “Nothnagel’s Spez. Path. u. Therap.,” 1899, xviii.
The changes in the biliary passages and the liver are, on the one hand,
the mechanical results of a partial or total obstruction to the flow of
the bile, and, on the other, of inflammatory processes. The blocking
of the common bile-duct and of the trunk of the hepatic duct leads to
the well-known symptoms of biliary engorgement; protracted continuance
of this condition has, as its sequela, general distension of the whole
biliary system and degenerative destruction of the liver-cells. If
the Ascaris is situated at some other part of the biliary system,
its presence causes a partial arrest of the flow of bile, with the
corresponding sequelæ. Many Ascarides perish in the ductus choledochus,
and here and in the gall-bladder they may supply the nucleus of a
gall-stone; deeper in the liver this does not appear to happen; the
dead _Ascaridæ_ here undergo a kind of maceration, disintegrate, and
may be completely absorbed; in many cases the worms continue to live
for a very long time in the biliary passages. When the worms infect the
biliary passages through the invasion of intestinal bacteria, liver
abscesses arise (Dauernheim,[901] Saltykow[902]). Leer[903] goes so
far as to maintain that _Ascaridæ_ may be the second most frequent
cause of liver abscesses. That Ascaris in the pancreas may simulate
liver abscess in a remarkable fashion is shown by Vierordt’s[904]
observation, which is quite unique, while _Ascaridæ_ have been found to
occur in isolated instances in the excretory ducts of the pancreas and
in its branches, where they have remained living for a long time.
[901] Dauernheim, _loc. cit._
[902] Saltykow, _Prag. Zeitschr. f. Heilk._, 1900.
[903] Leer, _Brit. Med. Journ._, 1906.
[904] Vierordt, _loc. cit._
It is no rare occurrence for _Ascaridæ_, in consequence of their
migration into the stomach, to be ejected by the act of vomiting, and
in such way to gain access into the upper air passages, or to find
their way during sleep into the nose or accessory sinuses (Mosler and
Peiper[905]) without giving rise to special symptoms. For example,
Troja[906] found in the frontal sinus of a cadaver a large coiled-up
Ascaris which occupied the whole cavity. Wrisberg[907] made the same
observation in the cadaver of a boy. Deschamps[908] and Fortessin[909]
mention an Ascaris being met with in the antrum of Highmore.
Observations of the discharge of living or dead Ascarides from the
nose are frequently recorded. To this class belongs the case mentioned
by Albrecht,[910] in which an Ascaris was removed from the nose of a
girl, aged 7; also the case recorded by Benievini,[911] from the nose
of one of whose friends a worm escaped; he had suffered from the most
violent headaches, fainting fits, dimness of vision and vomiting; after
the escape those untoward symptoms disappeared. Similar records have
been made by Forest,[912] Lanzoni,[913] Langelott,[914] Tulpe,[915]
Reisel,[916] Fehr,[917] Bruckmann,[918] Bahr,[919] Slabber,[920]
Lange,[921] and Chiari.[922] A rarer case is that recorded by
Haffner,[923] that of a child, aged 4, in whom an Ascaris reached the
nasal cavity through the act of vomiting, and from there it gained
access through the naso-lachrymal duct and the inferior lachrymal sac
into the lower punctum lachrymale, from which half of it protruded.
[905] Mosler and Peiper, “Nothnagel’s Handb.,” 1894, vi.
[906] Troja, Napoli, 1771.
[907] Wrisberg, _see_ Blumenbach, Göttingen, 1907.
[908] Deschamps, _see_ Blass, “Diss. Strasburg,” 1902.
[909] Fortessin, _see_ Bardeleben, “Lehrb. d. Chirurgie,” 1875.
[910] Albrecht, _Commer. Noricum. T. I. Annal._, 1739.
[911] Benievini, “Prol. Anat. d. Sin. front.,” Göttingen, 1779.
[912] Forest, _see_ Tiedemann, Mannheim, 1844.
[913] Lanzoni, _idem_.
[914] Langelott, _idem_.
[915] Tulpe, _idem_.
[916] Reisel, _idem_.
[917] Fehr, _idem_.
[918] Bruckmann, _Commer. Noric._, 1739.
[919] Bahr, _idem_.
[920] Slabber, _idem_.
[921] Lange, “Blumenbach’s Med. Bibl.,” Göttingen, 1788.
[922] Chiari, “Krankh. d. Nase,” 1902.
[923] Haffner, _Berl. klin. Wochenschr._, 1880.
Among the rarer causes of the occurrence of strange bodies in the
pharynx and naso-pharyngeal cavity, Jurasz[924] mentions in the first
place vomiting, which may afford opportunity for the more solid bodies
of the stomach contents, and even parasites of the digestive tract,
especially _Ascaridæ_, to become firmly lodged in the pharyngeal
or naso-pharyngeal cavity. _Ascaridæ_ may obtain access from the
naso-pharyngeal cavity to the middle ear by way of the Eustachian tube,
as has been observed by Reynolds[925] and Wagenhäuser[926]; in the case
recorded by Turnbull[927] (girl, aged 8, with pains in her ear) the
Ascaris apparently reached the external auditory meatus by the same
route.
[924] Jurasz, Heymann’s “Handb. d. Laryngol. u. Rhinol.,” iii.
[925] Reynolds, _Lancet_, 1880.
[926] Wagenhäuser, _Arch. f. Ohrenheilk._, 1889, xxvii.
[927] Turnbull, _Virchow-Hirsch Jahresbericht_, 1880.
The irritation of the larynx and air passages by _Ascaridæ_ is far more
dangerous than their penetration into the nose and naso-pharyngeal
cavity, because not only are attacks of suffocation, but sudden
suffocation thereby induced. Oesterlein[928] records a fatal attack
of choking from _Ascaridæ_ in the trachea. In a case recorded by
Smyly[929] of a boy, aged 3-1/2, tracheotomy for extreme asphyxia
was performed without relief. At the _post-mortem_ the cause of
the asphyxia was found to be an Ascaris in the trachea. Fürst[930]
collected twenty-five observations of invasion of the larynx and
trachea by Ascaris. Mosler[931] reports the case of a patient with
aphonia and dyspnœa from whose larynx an Ascaris was removed.
Donati[932] reports a case of four Ascarides in the larynx, and
Cerchez[933] of asphyxia from Ascarides in the larynx or trachea.
Wagner[934] records the case of a boy, aged 8, in whom a coil of worms
was ejected from the stomach by vomiting; the mass blocked the entrance
to the larynx and led to death from suffocation. A case similar to that
recorded by Smyly is communicated by Rabot[935]; it was that of a child
who underwent tracheotomy for diphtheria, and who was not relieved by
the operation; when, however, an Ascaris appeared in the cannula and
the parasite was removed the child breathed well. In Negresco’s[936]
case, that of a boy, aged 3, an Ascaris gained access to the larynx and
from there into the trachea, and a fatal issue from asphyxia resulted.
[928] Oesterlein, _Deutsch. Klin._ 1851.
[929] Smyly, _Dubl. Journ._, 1867.
[930] Fürst, _Wien. med. Wochenschr._, 1879.
[931] Mosler, quoted by Liesen.
[932] Donati, _Ann. Univ. de Méd. et Chir._, Milano, 1875.
[933] Cerchez, _Clinica_, 1891, iv.
[934] Wagner, _Deutsch. med. Wochenschr._, 1902.
[935] Rabot, _Soc. de Sci. méd. de Lyon_, September 9, 1904.
[936] Negresco, _Soc. de Méd. légale_, November 9, 1903.
The route by which _Ascaridæ_ obtain access to the urinary passages
must remain undecided. Schlüter[937] treated a woman, aged 60, with
retention of urine. Upon catheterization the hinder end of an Ascaris
hung out from the catheter opening; the anterior end was fixed in the
tube and the lumen was obstructed. Perhaps in the female sex _Ascaridæ_
travel from the gut into the vulva and from there into the bladder,
as they have already been observed in the vagina, where they cause
troublesome symptoms (pruritus pudendi).
[937] Schlüter, _Münch. med. Wochenschr._, 1902.
The diagnosis of ascariasis is not in general difficult; now and then
the worms are discharged spontaneously; if not, the ova, which cannot
be mistaken, can easily be detected in the fæces upon microscopical
examination. Epstein’s[938] method--namely, on every occasion to
obtain fresh material for examination--is much to be recommended. This
consists in introducing a Nelaton’s catheter into the rectum with a
rotatory motion and then drawing it out. A small portion of fæces
forced into the catheter opening is more than sufficient to demonstrate
the presence of ova of the parasites upon microscopical examination of
a preparation.
[938] Epstein, _see_ Seifert, “Lehrb. d. Kinderkrankh.,” p. 273.
In spite of all pressure on the part of relatives, treatment directly
against _Ascaridæ_ should not be carried out until the diagnosis is
certain.
As regards prophylaxis, much can be done by not throwing the worms,
when expelled, on to the dung-hill or into the privy, but straightway
into the fire. Metschnikoff[939] has issued a warning against
the consumption of unboiled or badly washed vegetables, salad,
strawberries, etc., and also against drinking polluted water.
[939] Metschnikoff, _Gaz. hebd. de Méd. et Chir._, 1901.
For the expulsion of the worms flores cinæ were formerly considered
the most useful means; now, however, santonic lactone--santonin--which
is prepared from them, is almost universally preferred. By many,
especially in practising among children, flores cinæ are still
recommended in the form of Störk’s worm electuary (consisting of flores
cinæ, rad. jalapæ, valerian and oxymel simplex). Guermonprez[940]
recommends them because he thinks that santonin only excites the worms
and consequently causes unpleasant symptoms. Besides, in the form of
the above-mentioned electuary, flores cinæ can also be given several
times daily with raspberry jelly up to 0·5 grm. to 2 grm. (children and
adults).
[940] Guermonprez, _see_ Seifert, _Deutsch. med. Zeitg._, 1885.
Santonin is prescribed either in single doses from 0·03 to 0·05 to
0·1 grm. with sugar in the form of powder, or else in oily solution.
When given in the latter form the absorption of the santonin in
the stomach is excluded and the whole quantity introduced is thus
enabled to reach the worms in the intestinal canal. Küchenmeister[941]
has already recommended combination of santonin with ol. ricini.
Lewin,[942] however, states that ol. morrhuæ, ol. olivarum, ol. cocos
and ol. cinæ can also be taken. In prescribing santonin in oily
solution Henoch[943] also prefers the combination with ol. ricini.
According to Lewin’s direction the prescription would run as follows:--
℞ Santonin 0·2 grm.
Ol. ricini. 20·0 grm.
Ol. cinæ æth. gtt. iv.
M., d.s.
S., one tablespoonful to be taken two to three times.
[941] Küchenmeister, _loc. cit._
[942] Lewin, _see_ Seifert, _Deutsch. med. Zeitg._, 1885.
[943] Henoch, _idem_.
If the patients should manifest a repugnance to castor oil, Starke’s
ricinus paste may be selected:--
℞ Santonin 0·2 grm.
Ol. ricini 20·0 grm.
Ol. cinæ æth. gtt. iv.
Sacch. albi. q.s.
Pasta moliis.
S., to be used for two days.
If necessary the first-mentioned mixture might be given in gelatine
capsules. Small children should be given 0·025 grm. santonin in warm
olive oil slightly sweetened with sugar (a teaspoonful) in the morning;
if in the course of the forenoon specimens of Ascaris escape, a second
dose should follow in the afternoon about two hours after the meal.
Older children should be given santonin in combination with castor oil
or calomel:--
℞ Santonini 0·01 to 0·02 to 0·03 grm.
Calomelan 0·025 grm.
Sacch. albi. 0·5 grm.
M.f.p. D. tal. dos. x.
S., one powder about six, seven, and eight o’clock on three consecutive days.
As santonin causes slight toxic symptoms such as urticaria, vomiting,
retention of urine, headache, vertigo, yellow vision (xanthopsia), it
is in every case advisable to follow with a laxative to expel the drug
from the body as speedily as possible. The urine is coloured yellow
from one to two days and assumes a scarlet red colour upon the addition
of alkalis; this, however, soon disappears, while it persists in the
case of rhubarb and senna.
In the place of santonin iodoform in the form of a powder mixed with
bicarbonate of soda is given by Schidlowsky[944] in doses up to 0·01
to 0·06 grm. three times daily, and a dose of castor oil on the day
after the iodoform is given. Thymol in addition to thymol enemas may
be tried, in doses up to 0·5 to 2·0 grm. per diem (Calderone,[945]
Hausmann[946]), also β-naphthol up to 0·45 grm. three times daily (Du
Bois[947]), and--
℞ Benzo-naphthol 2·0 grm.
Semin cinæ 1·0 grm.
Sacch. albi. 0·5 grm.
M., f.p. Divide in part. æq. xxii.
S., three to five powders daily.
[944] Schidlowsky, _see_ Seifert.
[945] Calderone, _idem_.
[946] Hausmann, _St. Petersb. med. Wochenschr._, 1900.
[947] Du Bois, _see_ Lenhartz in “Penzoldt-Stintzing’s Handbuch,”
p. 619.
(Ferran[948]), filmaron oil 1·0 to 2·0 to 3·0 grm. in gelatine
capsules, according to age (Bodenstein[949]). Brüning[950],[951]
recommends the so-called American worm-seed oil, derived from a plant
native to the United States, _Chenopodium anthelminticum_, Gray. It
is given in emulsion (ol. chenopodii anthelm. 10·0 grm., vitelli
ovi unius, ol. amygd., gi. arab. pulver. āā 10·0 grm., aq. destill.
200 grm.; f. emulsio) up to 0·25 to 0·5 grm. three times daily at
one to two-hourly intervals, or as a pure oil from 8 to 15 drops in
sugar and water; to be followed an hour after the last dose by oleum
ricini or pulvis curellæ. If no action takes place by the afternoon,
a laxative should again be given. The treatment frequently must be
repeated the next day. Thelen[952] appears to have had good results
from this drug.
[948] Ferran, _idem_.
[949] Bodenstein, _Wien. med. Presse_, 1906.
[950] Brüning, _Med. Klin._, 1906.
[951] _Idem_, _Deutsch. med. Wochenschr._, 1907.
[952] Thelen, “Diss. Rostock,” 1907.
Corsican moss (mousse de Corse), kamala, _Artemisia absinthium_,
valerian, semen sabadillæ, have all been supplanted by santonin and at
most are used as adjuvants for the latter.
*Oxyuris vermicularis* (Oxyuriasis).
_Oxyuridæ_ do not remain at rest in the gut, but leave it, generally
at night time, to migrate around the anus, into the gluteal folds, and
in females into the vulva and vagina and still higher up, giving rise
in these different sites to a whole series of irritative symptoms. In
the rectum, also, _Oxyuridæ_ give rise to such symptoms, which are
manifested in the form of catarrhal inflammation; numerous chronic
intestinal catarrhs are thus explained. The frequent coincidence of
hæmorrhoidal troubles with _Oxyuridæ_ may be attributed to the fact
that the veins of the rectum participate in those changes which have
been described as occurring in the intestinal mucosa. _Oxyuridæ_
may also give rise to prolapse of the anus, either by the tenesmus
they bring about having such a prolapse as its direct sequel, or the
proctitis that supervenes constituting a further etiological factor for
its occurrence (Ungar[953]). Anal fistulæ which still further increase
the trouble, and even rectal fistulæ, appear to be capable of onset in
consequence of the irritation of the mucosa brought about by _Oxyuridæ_
(Trendelenburg[954]). The conditions recorded by von Wagener[955] and
Ruffer[956] appear to be of interest. At the _post-mortem_ on a child,
aged 5, the former found fifteen to twenty quite minute nodules on some
Peyer’s patches, and in several of these _Oxyuridæ_ were found upon
microscopical examination between the calcareous concretions within
the patches. He presumes that the parasites penetrated the follicular
ulcers, and after healing of the latter that they died and became
calcified. In the case of a man who died from cirrhosis of the liver,
Ruffer found in the rectum, at a distance of about 6 in. from the anal
orifice, several tumours covered by the intestinal mucosa, the smallest
of which was the size of a pin’s head and the largest that of a walnut.
The tumours looked like calculi overgrown by connective tissue; under
the microscope, countless _Oxyuridæ_ ova were found in their interior.
[953] Ungar, _see_ Seifert, “Lehrbuch der Kinderkrankh.,” p. 246.
[954] Trendelenburg, _see_ Seifert, _idem_.
[955] von Wagener, _Deutsch. Arch. f. klin. Med._, lxxxi.
[956] Ruffer, _Brit. Med. Journ._, 1901.
The symptoms of irritation set up by these migrations from the
intestine are troublesome to the last degree; the pruritus thereby
induced is often unendurable; as this irritation from itching comes on
with especial severity during the night, the night’s rest is grievously
interfered with; many attacks of night terrors appear to be occasioned
by these worms. But the general condition suffers as well; the children
become pallid and affected with nervous excitability. Through the
act of scratching the irritated parts the ova of the parasites may
be conveyed by contaminated fingers directly into the oral or nasal
cavities, certainly also into the oral cavity by the contamination of
food (auto-infection). In the case of boys the sexual organs may be
excited sympathetically through irritation of the sacral nerves of the
rectum; girls may be induced to practise onanism in consequence of the
entrance of the worms into the vulva.
As a result of the itching irritation which the scratching gives rise
to, and of the irritation due to the parasites migrating to the area
surrounding the anus, congestion and inflammatory symptoms may arise
in the peri-anal and perineal regions (weeping eczema, Seifert),[957]
and these do not abate till after the removal of the oxyuriasis. Some
authors speak of an oxyuriasis cutanea (Majochi[958]), in the more
limited sense of a dermatitis intertriginoides. So far five such
cases have been recorded, one each by Szerlecky,[959] Michelson,[960]
Majochi,[961] Barbagallo[962] and Vignolo-Lutati.[963] Szerlecky’s case
was that of a young woman with intertrigo over the thighs (the skin
was covered as if with leather); Michelson’s case was that of a boy,
aged 13, with intertrigo on the skin of the genito-crural fold, of the
scrotum and of the thigh; Majochi’s was that of a man, aged 38, with
the same localization; Barbagallo’s case was that of a boy, aged 14,
in whom the dermatitis extended to the hypogastrium (rhagades on the
scrotum); and Vignolo-Lutati’s case was that of a man, aged 24, with
intertrigo of the peri-anal and perineal region, of the scrotum and the
inner side of the thigh.
[957] Seifert, “Lehrb. d. Kinderkrankh.,” and Lesser’s “Encyklop. d.
Haut-u. Geschlechtskrankh.,” p. 373.
[958] Majochi, _Boll. d. Sci. med. d. Bologna_, 1893.
[959] Szerlecky, _Journ. Ann. Med. prat._, Paris, 1874.
[960] Michelson, _Berl. klin. Wochenschr._, 1877, xxxiii.
[961] Majochi, _loc. cit._
[962] Barbagallo, _Gaz. d. Osp._, November 16, 1900.
[963] Vignolo-Lutati, _Arch. f. Derm._, lxxxvii, pt. 1.
On leaving the gut, _Oxyuridæ_ frequently migrate to the stomach, to
the œsophagus, to the mouth, to the nasopharyngeal cavity, and into the
nose (Zarniko[964]) (the localization in the nose has been referred to
as associated with the possibility of auto-infection--_see_ p. 695 as
to the development of embryos from the ova in the moist nasal mucosa).
Still the occurrence of _Oxyuridæ_ in the nose is among the greatest
of rarities. Chiari[965] records the case of a girl, aged 14, who
suffered from pains at the root of the nose and in the left side of the
forehead; female specimens of _Oxyuris vermicularis_ were evacuated
from her nose on several occasions. A similar case is recorded by
Hartmann[966]; it was that of a girl, aged 13, with epileptiform
convulsions and psychic disturbances; numerous Oxyurides frequently
escaped from her nose. With their departure the symptoms of irritation
of the central nervous system also disappeared. Rheins[967] records a
case, that of a woman, in which a specimen of _Oxyuris vermicularis_
was discharged from the right nostril during the act of sneezing.
Proskauer[968] found in the nose of a woman, aged 30, a conglomerate
of from fifteen to twenty very small worms which proved to be Oxyuris
embryos.
[964] Zarniko, “Die Krankh. d. Nase, u.s.w,” S. Karger, Berlin, 1905.
[965] Chiari, “Erfahr. auf d. Gebiete der Hals- u. Nasenkrankh.,” Wien,
1887.
[966] Hartmann, _Naturforscherversamml._, Köln, 1889.
[967] Rheins, “Der prakt. Arzt.,” 1893.
[968] Proskauer, _Zeitschr. f. Ohrenheilk._, 1891.
The diagnosis of oxyuriasis is not difficult to make, as the
troublesome sensations in the anus and about the genitals necessarily
suggest the presence of _Oxyuridæ._ As a rule the small white worms
are seen crawling about over recently evacuated fæces, or the ova are
found upon microscopical examination of soiled matter adhering to the
anus, or in scrapings removed with the spatula from the surface of the
skin (in the case of oxyuriasis cutanea).
Prophylaxis has to be directed to infection with Oxyurides
generally, on the one hand, and, on the other, to the possibility
of auto-infection. With reference to the first-mentioned point,
Metschnikoff’s[969] directions should be borne in mind, to the effect
that badly washed vegetables, salad, etc., ought not to be eaten
(vegetables to be rinsed with boiling water), and also that the
members of the family of the diseased individual should be examined
for _Oxyuridæ_ and eventually be treated (Heller[970]). With regard
to the second point, one has to observe strict cleanliness in general
(Barbagallo[971] found ova of the parasites in the layer of dirt under
the finger-nails).
[969] Metschnikoff, _Med. Klin._, 1907, xlii, p. 1284.
[970] Heller, _Deutsch. Arch. f. klin. Med._, lxxvii.
[971] Barbagallo, _loc. cit._
Treatment of oxyuriasis must be of a twofold nature; first, medicinal,
the administration _per os_ of vermicidal drugs in combination with
purgatives; and secondly, local treatment of the gut by means of
enemata, suppositories and high injections. Following the method
prescribed by Ungar,[972] pulv. glycyrrhizæ co. is first given in
the case of smaller children, castor oil or calomel in that of those
older, in order to evacuate the intestine, and four times daily on
two days following one another a dose of naphthalin, not directly
after meal-time, but as far as possible in the interval between two
meals, and at the same time the ingestion of fatty or oily nutriment
is as far as possible to be avoided. After eight days this treatment
should be repeated, and under certain circumstances once again after
a further interval of a fortnight. The dose varies between 0·05 and
0·1 grm. (children of 1 year old), 0·1 to 0·2 grm. (children of 2 to
3 years old) and 0·2 to 0·4 grm. (children of 4 to 10 years old).
Dornblüth[973] employs the same medicament in a form only slightly
modified from Ungar’s method, Barbagallo[974] gives internally only a
purgative (decoct. sennæ cum natr. sulfur). Thymol, santonin, kousso,
kamala or valerian may be tried instead of naphthalin. For enemata
the following are employed: naphthalin in a solution of 1 in 50, ol.
olivar. or thymol 0·1 in 200 aq. destill., diluted solutions of lysol,
menthol in 1/2 per cent. oily solution, salicylate of soda in watery
solution, decoctum tannaceti with santonin, with the addition of some
drops of ol. terebinth. (Barbagallo). Decoctions of garlic, infusion of
valerian, sulphur water (sublimate is to be avoided), aq. calcariæ, ol.
olivarum camphoratum (Vignolo-Lutati). Santonin 0·1 grm. is the best
to employ for suppositories.
[972] Ungar, _see_ Seifert, “Lehrb. d. Kinderkrankh.”
[973] Dornblüth, _Arztl. Zentral-Anzeiger_, 1903.
[974] Barbagallo, _loc. cit._
For high injections, large quantities of plain water are employed (2
to 4 litres), or soapy water (0·2 to 0·5 per cent. solution of sapo
medicatus, Heller,[975] Still[976]), 1/2 per cent. salicylic acid
solution or liq. alum. acet. (one tablespoonful to a litre of water,
Dornblüth[977]), or gujanosol (2 to 3 to 4 to 5 per cent. solution,
Rahn[978]). The employment of benzine for such high injections is not
advisable according to the experience of Senger,[979] owing to the
symptoms of poisoning after the external application of benzine, at
least not in the case of young children.
[975] Heller, _loc. cit._
[976] Still, _Brit. Med. Journ._, 1899.
[977] Dornblüth, _loc. cit._
[978] Rahn, _Münch. med. Wochenschr._, 1905.
[979] Senger, _Berl. klin. Wochenschr._, 1907, xxxviii.
That diseases of the intestine which are accompanied by frequent
thin fluid evacuations may lead to recovery from oxyuriasis has
frequently been observed by us in the case of young children who
have suffered from dysentery (Seifert[980]). Inunctions of cod-liver
oil appear to be very valuable in the treatment of oxyuriasis
(Szerlecky, Vignolo-Lutati), whilst those with mercurial ointment may
easily increase the inflammatory symptoms. The luxury recommended by
Esser,[981] that patients every evening before going to sleep should
have the female _Oxyuridæ_ picked from the anal fold in the knee-elbow
position is one which is certainly only in the power of a few people to
carry into execution.
[980] Seifert, _Deutsch. med. Zeitg._, 1885.
[981] Esser, _Schweiz. Korrespondenzbl._, 1893.
An essay has been published by Hippius and Lewinson (_Deutsch. med.
Wochenschr._, 1907, xliii.) in which the relationship of _Oxyuridæ_
to appendicitis is considered and the treatment of oxyuriasis is
discussed. The instructive case recorded appears to show that germs
through _Oxyuridæ_ gain access to the tissue of the appendix,
and, indeed, are carried in by them. In view of this more recent
communication as to the part which intestinal parasites play in the
etiology of appendicitis, it seemed to me [O. S.] to be worth while
to interrogate my surgical colleagues as to this point. About 2,000
appendicectomies have been jointly performed by Drs. Burkhardt,
Enderlen, Pretzfelder, Riedinger, Rosenberger and Siber, and in not
one of these cases could entozoa be found to be a possible cause
of the appendicitis. Such figures without doubt speak in favour of
the fact that even if in _individual_ cases entozoa might come into
reckoning as a possible cause, such an etiological factor must be
classed among the greatest of rarities. My colleague, Dr. Ries, who
practised for ten years in Mexico, informed me that there practically
speaking every Indian without exception harboured parasites of
the most varied kind, and that in spite of the very extensive
professional standing he enjoyed among these people he never had
under observation among them a single case of appendicitis. As far
as the observation of the authors in question as to the treatment of
oxyuriasis is concerned, it must be energetically directed to the
employment of local measures for the intestine; they maintain that
the use of enemata would be irrational, and that it is astonishing
that this method has been able to maintain its standing down to the
present day.
*HIRUDINEI* (Leeches).
The only one of the leeches that comes under consideration from the
clinical point of view is _Limnatis nilotica_ (_Hæmopsis sanguisuga_),
which obtains access to the mouth with drinking water, and becomes
lodged, even in the case of man, in the pharynx, larynx, trachea,
œsophagus and nose.
Amongst the causes of severe hæmorrhage from the pharynx Jurasz[982]
mentions the occurrence of leeches in that region: in Northern Europe
this must be accounted one of the greatest of rarities, whilst at
all times in southern countries, such as South Italy, Spain, Greece,
Algiers, Tunis and Egypt, it appears to have been more frequent.
Even the physicians of antiquity had much to say about it. Upon the
occurrence of blood-stained expectoration, Hippocrates recommends
the oral cavity to be examined to see whether a leech is not present
in it. Galen speaks of hæmatemesis due to the presence of leeches in
the pharynx and stomach. Similar mention is found in the writings of
Celsus, Asclepiades, Scribonius Largus, Dioscorides, Aëtius, Oribasius,
Paulus Aegineta and others. In recent times, Cortial[983] has published
observations relating to this subject which he had the opportunity of
making in Constantine. Palazzolo[984] also in Sicily found leeches
in two cases in the pharynx, in one case on the posterior wall, in
the other in the crypt over the left tonsil. According to Roset,[985]
leeches adhere by preference behind the uvula, simulating hæmatemesis
and hæmoptysis, and the persistent hæmorrhages they give rise to may
lead to severe anæmia. Leeches are found in still greater frequency in
the larynx than in the pharyngeal cavity. Huber[986] records several
observations of this kind in his historical and therapeutical study. In
the case of a man, aged 64, Ramon de la Sota y Lastra[987] observed a
leech on the nodulus epiglottidis; this was removed with the forceps.
In the case recorded by Photiades,[988] a leech had remained adherent
to the vocal cord for more than twenty-two days. Maissurianz[989]
records two such cases: in one the leech had remained in the sinus
morgagni for three weeks, in the other in the same place for ten
days. The case recorded by Schmolitschew[990] is an interesting one;
it was that of a woman who for four days had suffered from violent
hæmoptysis, the cause of which was a leech that was fixed on the
laryngeal wall of the epiglottis close above the vocal cords. In his
case (that of a soldier), Godet[991] was forced to perform thyrotomy
to remove the leech from the larynx. Ficano[992] removed a live leech
with the forceps from the lower laryngeal cavity in a man, aged 30.
Massei[993] reports a similar case. The case reported by Winternitz
and Karbinski[994] was that of a peasant girl, aged 16, who suffered
from coughing, hoarseness, and blood-stained expectoration; a leech
had lodged on the root of the epiglottis. Aubert[995] removed a leech
from the larynx of a woman after the performance of tracheotomy.
Seifert[996] reports three cases: in the first the leech had become
fixed to the left vocal cord, in the second it was found in the
lower laryngeal cavity, and in the third on the border of the left
ligamentum aryepiglotticum. Leone[997] has published the case of a
leech in the larynx, Martin[998] two cases with the leech lodged in the
lower laryngeal cavity, Berthoud[999] a similar case, Palazzolo[1000]
two such cases, Panzat[1001] one case (lower laryngeal cavity).
Moucharinski[1002] reports a case in which the leech had stayed more
than twenty days in the larynx. Martin[1003] easily removed a leech
from the posterior portion of the vocal cord with the forceps. Vieus
and Nepeon[1004] record a case of a leech in the larynx. It is quite
exceptional for leeches to gain access to the trachea; cases of this
kind have been recorded by Aubert,[1005] Vicano,[1006] Ridola[1007] and
Tapin[1008] (the leech was firmly fixed to the bifurcation and caused
coughing, hæmoptysis and attacks of asphyxia; it was easily removed by
the aid of a tracheal tube). Now and then leeches are found in the nose.
[982] Jurasz, Heymann’s “Handb. d. Laryng. u. Rhinol.,” 1899, ii.
[983] Cortial, _Union méd._, 1886.
[984] Palazzolo, _Bull. del. mal. dell’ orecchio, etc._, 1895.
[985] Roset, _Rev. d. Cienc. méd. de Barcelona_, 1907, ii.
[986] Huber, _Deutsch: Arch. f. klin. Med._, xlvii.
[987] Ramon de la Sota y Lastra, _Rev. méd. de Sevilla_, 1883.
[988] Photiades, _Int. Zentralbl. f. Laryng._, 1884.
[989] Maissurianz, _St. Petersb. med. Wochenschr._, 1883.
[990] Schmolitschew, _Wratsch_, 1884.
[991] Godet, _Arch. de Méd. et Pharm. milit._, 1887.
[992] Ficano, _Rev. de Laryng._, 1890.
[993] Massei, _Int. Journ. of Laryng._, 1890.
[994] Winternitz and Karbinski, _Prag. med. Wochenschr._, 1890.
[995] Aubert, _Echo méd._, 1891.
[996] Seifert, _Rev. de Laryng._, 1893.
[997] Leone, _Boll. del. mal. dell’ orecchio, etc._, 1892.
[998] Martin, _Arch. de Méd. et Pharm. milit._, 1891.
[999] Berthoud, _ibid._, 1893.
[1000] Palazzolo, _Boll. del. mal. dell’ orecchio_, 1895.
[1001] Panzat, _Arch. de Méd. et Pharm. milit._, 1896.
[1002] Moucharinski, _Wratsch_, 1896.
[1003] Martin, _Rev. barcelon de enf. de oido_, 1906.
[1004] Vieus and Nepeon, _Monatsschr. f. Ohrenheilk._, 1884.
[1005] Aubert, _Echo méd._, October 12, 1891.
[1006] Vicano, _Boll. del. mal. dell’ orecchio, etc._, 1892, ix.
[1007] Ridola, _Arch. ital. di Laryng._, 1894, ii.
[1008] Tapin, _Siglo med._, March 16, 1907.
Lusitanus[1009] relates the case of a man who suffered from severe
headaches. A medical man ordered the application of a leech to the
anterior portion of the nostril. Owing to the carelessness of the
surgeon the leech crawled right into the nose; it was impossible to
extract the leech or to kill it, and it produced a severe hæmorrhage
which led to the death of the patient within two days. In a case
recorded by Sinclair,[1010] a leech, _Hæmopsis sanguisuga_, gained
access to the nose of a boy, aged 3; it remained there a fortnight;
it caused frequent attacks of epistaxis and in the end it was removed
by means of forceps. Condorelli-Francaviglia[1011] records a case in
which severe epistaxis was caused by a leech which had probably entered
the anterior portion of the left nostril by way of the pharynx and
become tightly fixed there. It was seen by posterior rhinoscopy, and
was removed from in front by means of slightly curved forceps. Sota
y Lastra[1012] mentions the occurrence of leeches in the nose, and
Keng[1013] reports the case of nasal obstruction from a leech. The
removal of leeches is effected by means of injections or by the direct
sprinkling of salt or acid solutions on their bodies, which brings
about their detachment. When possible a previous attempt should be made
to seize them with forceps so as to make their immediate extraction
possible. The species of Hæmadipsa (Looss[1014]) live in tropical
regions in moist places on the ground or in the jungle. They climb
bushes and even trees with astonishing rapidity upon the approach of
larger animals and also of man (whom they clearly recognize from the
vibration of the ground caused by footsteps). From thence they let
themselves fall on their victims to suck their blood. Their bites are
generally painless, and of themselves not dangerous, but if they are
unusually numerous they rapidly accumulate on the body in large numbers
and give rise to marked debility and, if the wound become infected, to
severe complications and even death. On the other hand, under careful
treatment the wounds heal easily and fairly rapidly.
[1009] Lusitanus, _see_ Seifert in Heymann’s “Handb.,” p. 599.
[1010] Sinclair, _Brit. Med. Journ._, June 20, 1885, i.
[1011] Condorelli-Francaviglia, Spallangini, 1892.
[1012] Sota y Lastra, _Rév. méd. de Sevilla_, 1887.
[1013] Keng, _Scot. Med. and Surg. Journ._, October, 1899.
[1014] Looss, “Handb. d. Tropenkrankh.,” v. Mense, i, p. 194.
Firm leather and firmly adhering clothes afford no certain protection
against the attacks of these leeches, as they know how to force
themselves with extraordinary rapidity through the narrowest
interstices between the clothes and thus gain access to the skin.
When they have sucked their fill--and this may take several hours to
accomplish--they fall off of themselves. To effect an earlier removal
drops of irritative or corrosive fluids are employed (salt solutions,
acids, etc.). Tearing away the leech by force should be avoided, as in
this way portions of the leech’s body may be left behind in the wound
and inflammation be set up.
ARTHROPODA.
*Leptus autumnalis* (Grass, Harvest, or Gooseberry Mite[1015]).
In the hot season of the year, that is, during the months of July and
August, it is noticed that those people who stray amongst syringa
bushes or who pick gooseberries or kidney beans are attacked by
the _Leptus autumnalis_. On the uncovered parts of the body there
appear numerous red spots and papules, which itch and burn smartly.
The itching does not commence diffusely, as in the case of scabies
(MacLennars[1016]), but is limited to the particular points where the
parasite is situated. There are especial outbreaks of itching in the
morning, arising perhaps from the hatching of ova in the host after
lying in the warmth of the bed.[1017] Leptus frequently provokes
general erythema, eczematization or severe feverish urticaria,
which in France is known by the name of fièvre de grain (Mégnieu,
Besnier[1018]). If the individual efflorescences be carefully examined,
there will be noticed almost without exception a minute boss towards
the centre, noticeable by its yellowish-red colour. If an attempt is
made to remove it with the point of a needle or to scrape it off the
surface, one can often perceive, even with the naked eye, a small
reddish creature moving actively about. The treatment of these very
troublesome symptoms consists in warm baths with soapy lavages, also
lavages with alcohol, spirit salmiac (G. P.), 5 per cent. carbol or
creolin solution, diluted vinegar, benzine, emulsions of balsam of
Peru, rubbing in sulphur ointment (Sandwith[1019]); ointments of
creosote or eucalyptus are recommended. Other grass and grain mites
also occasionally penetrate the skin of man and produce transitory
but sometimes very severe eruptions, urticaria and eczema papulosum,
as Geber[1020] and subsequent to him Josai[1021] have reported of the
barley mite. In sensitive individuals the skin becomes bright red, to
a greater or less extent their temperature is raised and frequently
slight febrile affections are present. If the inflammatory skin
symptoms have reached their culminating point after three or four days
and no fresh complications arise, they only remain for a short while,
the effects of scratching and pigment spots being left.
[1015] There is no reason for calling this the gooseberry mite. It is
rarely found on this fruit. The gooseberry mite is _Bryolia pretiosa_.
[1016] MacLennars, _Lancet_, 1905.
[1017] [This cannot be the case, as _Leptus autumnalis_ is the larval
form of _Trombidium holosericeum_.--F. V. T.]
[1018] Sack, “Handb. d. Hautkrankh.,” v. Mraček, 1907.
[1019] Sandwith, _Lancet_, 1905.
[1020] Geber, “Handbuch d. Hautkrankh.,” in v. Ziemssen’s “Handbuch d.
spez. Pathol. u. Therap.,” 1884, xiv.
[1021] Josai.
*Kedani, Akaneesch* (The Japanese River or Inundation Disease).
This disease is only known in Japan, and is limited to the
neighbourhood of some great rivers on the west coast. The people
mostly attacked are those who cut the hemp harvest in the infected
localities, occasionally those who transport it or come into contact
with it (Looss[1022]). The disease is frequently manifested in the
form of indefinite disturbances of the general condition; it commences
generally on the sixth day after the presumed infection with rigors,
headaches, feeling of weakness, swelling of the lymphatic glands in the
loin or in the arm-pits; in the periphery a black dry scab is formed.
In addition there is an intense conjunctivitis, and added to symptoms
of fever an exanthema resembling measles that lasts from four to seven
days. There is frequent delirium and difficulty of hearing which
persist for a long while. Obstinate constipation is a striking symptom.
At the end of a fortnight, earlier in slighter cases, the fever
commences to abate and a rapid convalescence sets in. In pregnant women
abortion with fatal issue is frequent. With regard to prophylaxis,
Baelz[1023] recommends as rapid a cultivation of the soil as possible,
which has led to a speedy disappearance of the disease in districts
where it was once dreaded. Treatment is symptomatic. Japanese do not
tolerate antipyretic drugs as well as Europeans.
[1022] Looss, “Handbuch d. Tropenkrankh.,” v. Mense, p. 195.
[1023] Baelz, _Virchow’s Archiv_, lxxviii.
Dermanyssus gallinæ (avium).
During the day the resort of bird mites is in the droppings and in the
woodwork, etc., of cages in which canaries, crossbills and parrots are
kept; in the crevices of doors, in the chinks between the board planks
of bedsteads, so that at night they may seek some domestic animal to
suck the blood and so satisfy their hunger. It is by no means rare
for young animals, chickens and unfledged pigeons, etc., to perish
in consequence of the great loss of blood. This nocturnal habit of
life explains why no mites can be found during the day in spite of
the most careful examination of the human body, to which they may be
transmitted. On the uncovered parts of the body they not only cause
severe irritation, but also severe diffuse itching erythema and eczema.
Thorough disinfection of the cages by hot solution of caustic potash,
in addition, sprinkling over with tar, red carbolic acid or petroleum,
thoroughly powdering over the birds with flores pyrethræ, washing with
water containing oleum anisi, washing the walls, doors and bedsteads
with soap, disinfection of the mattresses, linen and clothes, will
protect against further infection. In the case of man the disease needs
no special treatment, as the eruptions generally disappear after some
days. Heinecke[1024] recommends lavages with 1 per cent. carbolic acid
solution. [_Vide_ also p. 492 in body of this work.--F. V. T.]
[1024] Heinecke, _Münch. med. Wochenschr._, 1901.
[_Dermanyssus hirundinis_, Hermann, is identical with this species. By
far the best treatment is with paraffin or kerosene oil applied to the
places where they pass the day.--F. V. T.]
Ixodes reduvius (ricinus).
The female is occasionally transmitted to the human skin, and bores its
proboscis deep into it and sucks itself full of blood. At sensitive
points of the cutaneous surface--for example over the skin of the
penis--a feeling of severe pain is produced. Buy’s[1025] observations
as to the geographical distribution of the _Ixodinæ_ show that in all
lands in which cattle, horses, sheep and dogs exist, _Ixodinæ_ are to
be found. Recent observations show that the _Ixodinæ_ play an important
part in the transmission of Hæmosporidia (_vide_ body of work, pp.
493, 494). Sprinkling with oil, vaseline, benzine, ether, petroleum,
naphtha, turpentine (Jelgenum[1026]), will easily lead to the removal
of the parasite; if the body is torn away with violence and the
proboscis is left sticking in the skin, the presence of the latter will
give rise to inflammation and suppuration.
[1025] Buy, “Histoire naturelle et médicale des Ixodes,” “Thèse de
Lyon,” 1906.
[1026] Jelgenum, _Med. Weekblad v. Noord- en Zuid-Nederland_, 1901, i,
No. 24.
*Sarcoptes scabiei* (Scabies).
The disease produced by _Sarcoptes scabiei_ shows itself in
polymorphous areas, such as accompany eczema, and are produced on the
one hand by the Sarcoptes alone and on the other hand by the scratching
with the nails. The localization of both kinds of efflorescences is
different from those which are produced by the Sarcoptes; they occur as
papules, vesicles, pustules and mite-tracks, and their usual situation
is between the fingers, on the ulnar border of the hand, on the wrist,
on the palm of the hand, on the anterior border of the axilla, on the
penis and at the base of the thorax. The excoriations are situated on
the forearm, over the thigh, over the abdomen, and may be distributed
in greater or less degree over the whole body; the back and the face
only remain free. The symptoms consist in violent itching, the onset of
which specially takes place at night.
The mite-tracks are fine curving lines, curved like *a*, *u*, *c*, or
*s*, which appear as if they had been scratched with a fine needle.
Upon closer examination with the magnifying glass one sees in their
course small openings. These openings, in persons who keep themselves
clean, are scarcely coloured; but in patients whose occupations
necessitate their being associated with coloured or dirty substances,
they are dark. The length of the tracks varies from some millimetres to
1-1/2 to 2 cm. They are at the one end, where the Sarcoptes is embedded
in the epidermis, widened like a funnel and slightly exfoliated. The
track at this point is sharply defined; the mite shows through the
epidermis as a yellowish round point. In the course of the track there
develop papulæ, vesicles or pustules, which raise the level of the
track. The intensity of these inflammatory appearances depends upon
the susceptibility of the human individual and upon the capability
of the reaction of the skin. There are people in whom scarcely any
inflammatory symptoms make their appearance; on the other hand there
are some, especially children and lymphatic individuals, in whom severe
impetiginous ecthymatous pustules, together with their sequelæ, are set
up.
The results produced by scratching consist in papules, which usually
bear a small scab of blood, and are arranged in the form of striæ, in
eczematous surfaces, weeping or sanguineous scabs, vesicles, pustules,
etc. The complications that set in are frequently urticaria and even
furuncles, lymphangitis and inflammation of the glands, which now and
then is followed by the formation of abscesses in the glands.
The duration of the disease is unlimited; when untreated it leads to a
form of rare occurrence, that of scabies norvegica[1027]; in this the
collection of crusts and scales, in which a quantity of dead mites,
larvæ and ova are present, may become colossal.
[1027] [This is produced by a distinct species, _vide_
pp. 519–20.--F. V. T.]
The symptoms of scabies abate in the presence of intercurrent acute
diseases and reappear after the malady is over. The fact has for long
contributed to the idea of scabies being regarded as a disease capable
of being “driven in” upon the internal organs and forming metastases.
The diagnosis is rendered certain upon the discovery of a track.
Traces of scratching on the extremities and on the abdomen, papular or
pustular efflorescences between the fingers, toes, in the neighbourhood
of the wrist, of the elbow, on the anterior border of the arm-pit, on
the tuber ischii, in the girdle region, and especially the presence of
disintegrated tracts over the penis (prepuce and glans), will allow
of the diagnosis being made. Certain occupational eczemas (grocers,
lime-workers, maltsters, bakers and others), also prurigo, must be
borne in mind when diagnosing this disease.
The prognosis is always a favourable one. Even after such a long
duration and after such severe symptoms the disease may completely
clear up. There are, however, frequently left behind post-scabious
inflammatous and pruriginous conditions which only yield after
protracted treatment. Scabiophilia, which persists in certain patients
for a long time after the scabies has been cured, must here be
mentioned.
In the treatment of scabies four points must be kept in view. (1) The
mites and the ova must be killed by the treatment; (2) the treatment
must have regard to the intensity of the inflammatory symptoms; (3)
the clothes (body-linen) of the patients must be disinfected; the
bed-linen, the beds and the bedsteads must be cleansed; (4) when a
person suffers from scabies his entourage must be examined, and all
diseased conditions treated in the same way as under (3).
The treatment (1) should be preceded by a bath with thorough soap
ablution, and when the inflammatory symptoms are not too severe,
with green soap. After the bath the skin is dried and the scabies
remedy proper applied in warmth. Sulphur preparations receive
first consideration; among such Vlemingkz’s mixture occupies a
prominent position; this is rubbed in for half an hour by means of a
strong camel-hair brush, to be followed by another bath and powder
applications after drying. Repeat this method for three days one
after the other, or for two days, and a third time eight days later.
The latter method is worthy of recommendation as the ova, which
perhaps resist the parasiticide action, have by this time developed
into larvæ, and the latter can then be destroyed with certainty. The
remaining sulphur preparations, which are specially employed in the
form of ointments, are more complex, as the ointment should remain
on the skin. Helmerisch’s and Wilkinson’s ointments are the kinds
specially employed. Nagelschmidt[1028] recommends thiopinol as a very
suitable sulphur preparation in the form of baths or as a 10 or 5 per
cent. ointment in the following way: Upon his reception the patient
is given a thiopinol bath, in which he remains for thirty minutes.
Immediately afterwards 30 to 40 grm. 10 per cent. thiopinol vaseline is
carefully rubbed in. The rubbing is repeated daily, and the treatment
is concluded on the second to fourth day with a second thiopinol
bath. Thiopinol produces no more irritation than the ordinary sulphur
ointments; it is, however, much more penetrative and more capable of
absorption.
[1028] Nagelschmidt, _Med. Klin._, 1907, xxxv.
We frequently make use of Kaposi’s naphthol ointment, as it renders
the skin supple, causes proportionately little irritation, and has but
little smell. Treatment with balsam of Peru is certainly expensive,
but in the slighter attacks it is relatively the simplest. We give
the patient a bath, have him thoroughly dried and rub in 30 to 40 to
50 grm. balsam of Peru carefully and evenly all over, wrap him in
a covering of wool, and make him rest in bed for twelve to fifteen
hours, to be followed by a bath with careful cleansing with soap;
this treatment need rarely be repeated. The balsam of Peru can be
applied undiluted for the rubbings or mixed with ung. glycerini, or
resorbin or glycerine in equal parts. [Norman Walker uses balsam of
Peru 1/2 oz. dissolved in rectified spirit; to be painted on with a
brush.]--J. P. S. The manufacturers name the undiluted product of
the active constituent of balsam of Peru, benzoic acid benzyl-ester,
Peruscabin. For the treatment of scabies it is recommended by
Sachs[1029] that it should only be administered when mixed with ricinus
oil, under the name of Peru oil, in applications repeated three times
within thirty-six hours.
[1029] Sachs, _Deutsch. med. Wochenschr._, 1900.
Sack[1030] also considers Peru oil a non-irritant, effectual, pleasant,
inodorous and non-staining drug. But he only allows the applications
to be used every twelve hours for three to four consecutive days
(altogether 200 to 300 grm. of Peru oil are requisite), and after
the sixth or seventh rubbing a bath should be taken with the use
of Dutch soap. Juliusberg[1031] considers this treatment specially
suited for private practice. Another modern drug is epicarin
([Beta]-oxy-naphthyl-ortho-oxy-meta-tolyol acid); this is applied in 10
to 20 per cent. ointments (Pfeiffenberger[1032]), epicarin 7·0 grm.,
cretæ alb. 2·0 grm., vasel. flavi 30·0 grm., lanolin 15·0 grm.,
axungia poric. 45·0 grm. (Rille[1033]); epicarin 15·0 grm., sapon.
virid. 5·0 grm., axung. poric. 100·0 grm., cretæ alb. 10·0 grm.
(Kraus[1034]); for children, epicarin 5·0 grm., lanolin 90·0 grm.,
ol. olivar. 10·0 grm. (Kaposi[1035]). Siebert[1036] lays stress upon
the odourlessness and colourlessness of epicarin ointment as a strong
reason for its use, and points out that it is a harmless drug, the
action of which is certain. Endermol (salicylic acid ointment) has
a destructive action on the mites even in a 0·1 per cent. ointment
(Wolters,[1037] Demitsch[1038]); it is, however, very expensive and
not wholly free from danger; and the same applies to nicotiana soap
(Taenzer,[1039] Schumann[1040]).
[1030] Sack, “Handb. d. Hautkrankh.,” v. Mraček.
[1031] Juliusberg, _Therap. Monatsh._, 1901.
[1032] Pfeiffenberger, _Klin. therap. Wochenschr._, 1900.
[1033] Rille, “Die Heilkunde,” 1900.
[1034] Kraus, _Allg. wien. med. Zeit._, 1900.
[1035] Kaposi, _Wien. med. Wochenschr._, 1900.
[1036] Siebert, _Münch. med. Wochenschr._, 1900.
[1037] Wolters, _Therap. Monatsh._, 1898.
[1038] Demitsch, _Wratsch_, 1905, iv.
[1039] Taenzer, _Monatsh. f. prakt. Derm._, xxi.
[1040] Schumann, _Allg. med. Central-Zeitg._, 1901.
To give an account in detail of the drugs and methods--old and
new--used in the treatment of scabies would far outrun the limits of
this work.
Demodex folliculorum.
It is not yet certain whether the _Demodex folliculorum_ is capable of
developing pathological conditions in man. Veiel[1041] assumes that
the hair follicle mite has no connection either with the formation of
comedones or even with sebaceous gland disease. Kaposi[1042] considers
that they cause no disease in man and cannot be regarded as a cause of
acne. Saalfeld[1043] clearly adheres to the same standpoint, similarly
so Jessner,[1044] who, when discussing comedones, makes no mention of
acne of hair follicle mites. Weyl[1045] and Geber[1046] adhere to the
opinion that the presence of a Demodex in man in contradistinction
to its presence in animals possesses absolutely no pathogenic
influence. On the other hand de Amicis,[1047] Majochi,[1048] and
Dubreuilh[1049] report single cases of pronounced circumscribed clear
brown pigmentations which they attribute to _Demodex folliculorum_.
In all these cases, moreover, as regards localization the affection
had a certain resemblance to pityriasis versicolor; nevertheless,
in the scales separated off with the scalpel no fungi were found,
but on the other hand Demodices in moderate quantity. In his earlier
cases Majochi has seen the Demodex in the secretion from meibomian
glands and had claimed it to be the excitant of chalazion and, as
Mibelli[1050] did, considered it to be the cause of some diseases of
the eyelids. Ivers[1051] found the parasite in 69 per cent. of normal
borders of the eyelids, and attributes a pathological signification to
it. Hünsche[1052] and Mulder[1053] arrive at the same conclusions; in
the light of their investigations the Demodex is found as a constant
accessory--certainly not in the meibomian glands, as it is limited
only to the internal part of the hair follicle. Lewandowsky[1054]
considers that it can hardly be demonstrated at present that the same
parasite which in individual specimens causes no symptoms is capable of
producing pathological conditions when markedly increased in numbers.
[1041] Veiel, v. Ziemssen’s “Handb. d. spez. Path. u. Therap.,” 1884,
xiv.
[1042] Kaposi, “Path. u. Therap. d. Hautkrankh.,” 1899.
[1043] Saalfeld, Lesser’s “Encyclop. d. Haut- u. Geschlechtskrankh.,”
1900.
[1044] Jessner, “Kompend. d. Hautkrankh.,” 1906, 3rd ed.
[1045] Weyl and Geber, v. Ziemssen’s “Handb. d. spez. Path. u.
Therap.,” 1884, xiv.
[1046] Weyl and Geber, v. Ziemssen’s “Handb. d. spez. Path. u.
Therap.,” 1884, xiv.
[1047] de Amicis, quoted by Lewandowsky.
[1048] Majochi, _Centralbl. f. Bakt._, xxv.
[1049] Dubreuilh, _La Prat. Derm._, Paris, 1901.
[1050] Mibelli, quoted by Lewandowsky.
[1051] Ivers, _ibid._
[1052] Hünsche, _Münch. med. Wochenschr._, 1900, xlv.
[1053] Mulder, _Weekbl. v. het Nederl. Tijdschr. v. Geneesk._, 1889.
[1054] Lewandowsky, _Deutsch. med. Wochenschr._, 1907, xx.
Treatment is by the removal of the comedones, above all, by their
mechanical removal by pressure with a watch-key and with the various
comedo-compressors, and by subsequent cleansing of the skin with ether,
benzine or spirit. If the eyelids should be affected with blepharitis
due to the presence of Demodex in large numbers, epilation and
administration of a parasiticide is recommended.
Demodex folliculorum canis.
Transmission from dog to man is in any case very rare, and by many
its occurrence is generally doubted. Nevertheless Gruby[1055] and
Remak[1056] claim that it is transmissible--an opinion which has also
been shared by Neumann[1057] and Zürn.[1058] The latter saw in the
case of a married couple who had the care of mangy dogs the onset of
diseased areas on their hands and feet, which were like those on the
dogs and contained the same parasites.
[1055] Gruby, quoted by Lewandowsky.
[1056] Remak, _ibid._
[1057] Neumann, _ibid._
[1058] Zürn, _ibid._
A. Babes[1059] also reports several observations which go to show that
persons who, to some extent, have been shown to have been in contact
with mange-stricken dogs have been attacked by a scabies-like eruption
localized over the thorax, abdomen, back and extremities; large numbers
of Demodices were found in the follicular pustules. Lewandowsky[1060]
reports one case--that of an Italian workman, who suffered from an
outbreak on the face, like impetigo; there was crust formation and
at the edge of the crusts the epidermis appeared like a narrow row
or border of vesicles. A small portion of the covering of the row of
vesicles was lifted off, and after slight warming examined in 40 per
cent. liquor potassæ. In this a large number of animal parasites of
the Demodex group were found, and without doubt _Demodex folliculorum
canis_ alone. Hünsche[1061] assumes that _Demodex folliculorum_
penetrates into the tissues and produces abscesses.
[1059] Babes, _ibid._
[1060] Lewandowsky, _Deutsch. med. Wochenschr._, 1907, xx.
[1061] Hünsche, _Münch. med. Wochenschr._, 1900, xlv.
Treatment first consisted in dusting with zinc amyl powder, but after
four days there was no change. After the regular use of xeroform as a
powder application, the affection cleared up within fourteen days.
INSECTA.
*Pediculus capitis* (Pediculus capitis) (Head Louse).
We find _Pediculus capitis_ in very young children and in others
more grown up to be the incessant and frequent cause of impetiginous
crust-forming eczemas. It is more frequent in girls than in boys. In
families it is endemic, in schools epidemic, but it also occurs in fair
frequency in female adults (servant maids, waitresses) who may pay
little attention to bodily cleanliness. The puncture of the parasites
sets up a severe irritation, which leads to violent scratching. The
consequences of this are the formation of nodules and pustules, crusts
and “weeping” patches; the hairs become felted and the final clinical
picture is that of plica polonica. The conditions of irritation which
are produced by these parasites and then by the scratchings of the
impetiginous, and frequently the very severe suppurative processes
of the hair-bed, lead to swellings in the neck and sometimes even to
glandular suppurations. The eczematous processes not infrequently
extend over the face, the neck and the thorax. Blepharitis and
conjunctivitis may be due to _Pediculus capitis_.
The means of infection are often very remarkable. Transmission from
one individual to another certainly often occurs, but infection may
take place in railway carriages and in other ways. A case under the
observation of a colleague in Frankfort is a most remarkable one: he
diagnosed pediculosis as the cause of a head eczema occurring among the
children of one of the best families there. The infection took place
through dolls adorned with human hair, in which the presence of nits
could be demonstrated.
The diagnosis of _Pediculus capitis_ is not difficult to make when
the hairs and hairy scalp are carefully examined for nits and living
parasites. In better families it is a good plan to point out the
_corpora delicti_ to their possessors and to make them aware of the
possible sources of infection.
As regards treatment, lotions of sabadill vinegar are recommended;
in slighter cases these are quite sufficient. In severe cases cure
will not result unless dressings of petroleum, naphthol ointment (5
to 10 per cent.) and balsam of Peru be applied. In the case of plica
polonica, the hair must be cut quite short (even in adults) so as to
control matting of the hair. To get rid of nits from hair that is not
matted, careful combing and washing with strongly alkaline fluids or
with hot vinegar is suitable.
*Pediculus vestimenti* (Clothes Louse).
The clothes louse attacks adults by preference, and with especial
frequency old and emaciated persons. It lives in the clothes, but
derives its nourishment from the body. At the moment at which
the clothes louse inserts its proboscis into the skin the person
experiences a slight sting, which, however, at once ceases to hurt.
If the body of the louse is sucked full of blood it falls off and the
individual has rest from it for a time. A wheal develops around the
hæmorrhagic area of the bitten spot and itches severely. The itching
goes on until the eruption is scratched all over. This is followed by
crust formation. When many parasites are present the itching reflexes
become more severe, and the patients scratch themselves considerably
and make long marks at those places where the Pediculi have been.
The localization of the scratching effects is characteristic,
corresponding with folds between portions of clothing (regions between
the shoulder-blades, wrist and neck). If the condition lasts for a
month, the scratching effects extend over the whole body, and secondary
efflorescences become associated with it, such as pustules, ulcers and
eczemas. Intermediate between this we find cicatrices and pigmentation,
the latter under certain circumstances extending over the whole body.
Sulla, Herod, Cardinal Dupet, Philip II, and others are said to have
died from louse disease. That even at present many human beings are
exposed to the danger of being devoured by lice is a fact that we have
had the opportunity of observing on several occasions. Only to record
one instance, a man, aged 65, was received into our clinic some time
ago in an absolutely neglected condition (he had been staying for some
weeks in a stable, lying on a wretched bed). The whole of the surface
of his body was covered with countless furuncles, of greater and less
size, which had partly become changed into undermined ulcers. Over the
ulcers and beneath their undermined edges Pediculi were swarming.
*Phthirius inguinalis* (_Pediculus pubis_) (Crab Louse).
The transmission of these parasites generally takes place during
coitus, and therefore they especially occur in the pubes. It is
possible also that transmission is effected through dirty clothes and
bed-linen and privy seats.[1062] Starting from the pubes the animals
crawl out over the other parts of the body provided with hairs to the
abdominal wall and the thorax (so far as these parts are furnished with
thick hair) to the arm-pits, the beard, the eyebrows; not, however, to
the hair of the head, or rarely so; among our numerous cases we have
never met with an example of the crab louse attacking the hair of the
head.
[1062] [A case of infection through a dirty station privy in
Switzerland came to my knowledge in 1899, and numbers of pediculi were
found there.--F. V. T.]
The irritation produced by the crab louse is extraordinarily severe,
especially during the night, as the warmth of the bed incites the lice
to active sucking. In consequence of the violent scratching indulged
in, eczemas are set up at the points attacked, and these often spread
to the neighbouring parts not covered with hair.
Of special interest is the onset of maculæ cæruleæ (tâches bleues) in
some persons affected with crab lice (people disposed to sweating seem
to be peculiarly liable to these). They consist in pale blue patches
of various size and shape, varying from that of a hemp-seed to that
of a lentil, and again to that of a nail in size and form. These are
found over the cutaneous surface of the abdomen, thorax and thigh,
and are often only seen by a good lateral illumination. Duguet[1063]
considers that the condition is a toxic erythema, that it is set up,
on the occasion of the bite of the parasite penetrating the skin, by
the poisonous substance derived from it. Oppenheim[1064] considers
that it is a colouring substance that is formed in the salivary glands
of the parasites, and which penetrates the skin when the insects
bite, and thus forms the maculæ cæruleæ. We have on several occasions
emulated the experiment of Duguet (trituration in a mortar of crab
lice freshly taken from the human body and inoculating the mass thus
obtained beneath the skin), and have similarly been enabled to produce
the maculæ cæruleæ experimentally, but we have certainly been unable
to determine which of the hypotheses is the correct one, the toxic
erythema or the colouring substance inhibition theory.
[1063] Duguet, _Annal. de Derm._, II Sér., i.
[1064] Oppenheim, “Handb. d. Hautkrankh.,” v. Mraček, 1907.
The diagnosis of phthirasis is very easy, for either the sexually
mature parasites or the nits are found on the hairs.
As regards treatment, grey ointment is regarded as a generally useful
application; it gives rise, however, to a slight eczema of the
genitals, especially in males, when injudiciously used. Geber[1065]
recommends petroleum or balsam of Peru, Oppenheim[1066] a 1 per
cent. sublimate solution for lotions, or a mixture of equal parts
of petroleum and benzine when the sublimate cannot be borne. The
use of a 5 per cent. ointment with hydrarg. oxid. flavum is worth
considering in treatment of pediculosis of the eyebrows and eyelashes.
The simplest method of treatment, and one with a radical effect, is
that by sulphuric ether recommended by Thomer.[1067] It certainly
produces a sharp burning sensation, but the living parasites and nits
are destroyed in one sitting. We prefer ether lotions as a rule, and
we thoroughly rub the affected parts with a pad of wadding well soaked
with the ether. The dead parasites and the nits fall on to what lies
beneath when the rubbing is done thoroughly, and the burning sensation
caused by the ether only lasts a few minutes.
[1065] Geber, _see_ Seifert, Lesser’s “Encyclop.,” p. 387.
[1066] Oppenheim, _loc. cit._
[1067] Thomer, _see_ Seifert, Lesser’s “Encyclop.,” p. 387.
*Cimex (Acanthia) lectularia*[1068] (_Cimex lectularius_) (Bed Bug).
[1068] _Vide_ genus Cimex, p. 534.
The puncture in the skin made by the bed bug gives rise to an
extraordinary amount of severe itching and a burning sensation, and
when the skin is sensitive wheals of remarkable size (_urticaria
ex cimicibus_). These eruptions that cause such severe itching are
scratched by those attacked, till very soon blood begins to flow, and
this generally leads to the formation of a dried crust of blood at the
point of eruption.
The diagnosis is not always easy, as urticaria arising in other ways
frequently leads to similar vigorous scratching and formation of
crusts of dried blood. Men who have some experience in this matter
(for example, commercial travellers), when they are attacked by severe
itching at night, are in the habit of striking a light and searching
in their bed and body-linen for the bugs, in order to be able to hand
over the _corpora delicti_ to the landlord if need be. The assumption
that the bugs in the East play an actual part in the propagation of
tuberculosis and bubonic plague has been proved by investigations
made by Nuttall[1069] to be at least very exaggerated if not wholly
without foundation. Further investigations may decide how far the bugs
participate in the transmission of kala-azar, as is believed by Rogers
to take place.
[1069] Nuttall, _see_ Sack “Handb.,” v. Mraček, p. 290.
The bed bugs must be exterminated by spraying the chinks and joints
in the boards with petroleum and benzine, pulling up the carpets and
cleansing the bedsteads. For the treatment of the bite itself the
methods recommended as an antidote against insects’ stings in general
are suitable: 2 per cent. carbol vaseline (Rosenbach[1070]), thymol
dissolved in spirit (1 in 50[1071]), æthrol or deci-æthrol, form-æthrol
(manufactured by Dr. Nordlinger, Flörsheim a. /M.), formol[1072]
(formol 15 parts, xylol 5 parts, acetone 44 parts, Canada balsam 1
part), with the aid of a pad of wadding placed over the part bitten,
lavages with vinegar, citron juice and spirit of salmiac.
[1070] Rosenbach, _Therap. Monatsh._, 1903.
[1071] _Leipzig. med. Monatsh._, 1907, vi.
[1072] _Chemist and Druggist_, August 25, 1906.
*Pulex irritans* (Human Flea).
The bite of the flea produces a slight discharge of blood about the
size of a pin’s head, which rapidly becomes surrounded with a circular
area similar to a patch of roseola. The redness fades away after a
longer or shorter while (several hours), whilst the discharge of
blood is to be seen for one or two days longer. In dirty people the
whole body may be covered with such discharges of blood. Individuals
with very delicate, sensitive skin, especially small children, show
true wheal formation at the site of the bite. In certain cases there
develops from one such single bite an urticaria that extends over a
large part of the body. The manner by which an irritating substance is
introduced into the skin upon biting by the bed bug and also by the
flea is clear. The bite is followed by a feeling of itching, which is
liable to rob nervous persons of their sleep. Sensitive individuals
are upset even by the fleas moving over the surface of the skin during
their rest at night.
Treatment consists in extreme cleanliness, capture of the parasites,
sprinkling the body and bed-linen with insect powders. The fleas are
difficult to remove from barracks, schools and hospitals.
*Dermatophilus* (*Sarcopsylla*) *penetrans* (Sand Flea).
The fertilized females penetrate into the skin with their heads, and
here they swell, in consequence of the numerous and growing eggs and
larvæ, to a white ball the size of a small pea, on which the head is
recognizable only as a small brown point.
In this way a small brown tumour arises, over which, at the
commencement, the skin is not reddened; after some days, however, it
becomes inflamed; in the centre of it a small opening is seen. If the
parasite is not extracted the skin that lies over it becomes destroyed
by suppuration, and thus becomes removed. At the commencement the
part affected itches, with increasing inflammation; the symptoms of
irritation become more severe and may amount to actual pain. If the
small suppurative processes be neglected, inflammation and gangrenous
and septic processes may arise. The region of the body sought out by
preference by the sand flea is the sole of the foot, the toes, under
the free ends of the nails and the digito-plantoid folds--more rarely
the scrotum, thigh and other parts are attacked (Scheube[1073]). The
number of parasites found on one person may amount to several hundreds.
[1073] Scheube, “Die Krankh. d. warmer Länder,” 1896.
Treatment consists in the removal of the parasites from the skin with
a needle or a small sharp knife and the application of a bandage.
Rubbing the feet with copaiba or Peru balsam, sprinkling them with
insect powder, or washing them with bay rum (Berger[1074]) acts as a
prophylactic or removes the irritation of the skin produced by the
parasites.
[1074] Berger, _Therap. Monatsh._, April, 1907.
Myiasis.
Under the name of myiasis we designate the complex symptoms which
parasitic dipterous larvæ give rise to in man (Braun), and we conceive
under the term myiasis externa (dermatosa s. cutanea) all lesions of
the human integument caused by fly larvæ and of the cavities covered
with mucosa therewith connected, such as the external auditory meatus,
the oro-nasal cavity, the urethra and vagina. The occurrence of
dipterous larvæ in the digestive tract is named myiasis intestinalia or
interna.
Myiasis externa.
The larvæ of a species of fly belonging to the _Muscidæ_, _Lucilia
macellaria_,[1075] are found in relative frequency in the nose,
especially in America and India.[1076] Riley[1077] has stated that the
screw-worm of Central America and of the United States is nothing else
than the larva of _Lucilia macellaria_, and also that the Brazilian
fly named “berna” may be no other than _Lucilia macellaria_. Their
offspring may set up inflammatory disturbances in the soft tissues of
man. This fly has a wide distribution, from the Argentine Republic to
Canada, also in the British portions of the East Indies, where the
disease is named “peenash.” This word is derived from the Sanskrit,
and is said to be a collective name for all diseases of the nose.
Lahory[1078] states that within a period of nine years ninety-one
cases of “peenash” occurred in Allyghar, two of these ending fatally.
_Lucilia macellaria_ is not at all timid but bold, like the house-flies
and blue-bottles, its relatives. It not only lives at no great distance
from human dwellings, and forces its way into villas and country
houses, but even attacks its victims without awaking them from their
sleep. Although this species shows a certain preference for nasal
cavities affected with catarrh or pus (v. Frantzius[1079]), and also
the external auditory meatus, as well as ulcerated or wounded parts of
the body, and even badly ulcerated skin carcinoma (Lutz[1080]), it is
not a rare thing for it to penetrate into one of the above-mentioned
cavities rapidly to deposit its eggs, without these parts having
been previously affected. The report also of Conil,[1081] in which
these flies bear the name of _Calliphora anthropophaga_[1082] is an
interesting one. Probably it was the same species of Muscid in the
cases of myiasis nasi observed by von Tengemann, Delasiauve,[1083]
Weber,[1084] Mankiewicz,[1085] and Kirschmann.[1086] In the case
recorded by Prima,[1087] and in that recorded by Britton,[1088] the
issue was a fatal one; in the latter the larvæ escaped through the
pharynx and nose; the hyoid bone and the soft parts of the palate
were destroyed, the speech and power of swallowing were hindered.
At the _post-mortem_ extensive destruction of the internal nose was
found, so that the nasal bones could only be kept in their position
by the aid of the external skin. Even during life 227 larvæ escaped.
Similar destructive processes were found in the case communicated
by Richardson.[1089] In two cases reported by Schmidt[1090] 300 and
350 larvæ were respectively removed from the nose, and the patients
recovered. Wolinz[1091] found his patient had lost consciousness,
and that in the pus filling up the entrances to the nose numerous
larvæ were moving; recovery followed. In the case communicated by
Adler,[1092] more than 150 larvæ escaped from the nose of an old man.
Curran[1093] states that people suffering from “peenash” frequently
die from meningitis. The cases reported by Pierre[1094] related to
the forms of severe myiasis frequently to be observed in Guiana. In a
patient who was suffering from typhus (? typhoid), Douglas[1095] found
the conjunctival sacs full of larvæ; in two other individuals the nasal
cavities were attacked.
[1075] [_Chrysomyia macellaria_, p. 587.--F. V. T.]
[1076] [_C. macellaria_, Fabricius, the screw-worm fly, is found in
tropical America and the West Indies. The genus is restricted to
America. The species from India is a Pycnosoma.--F. V. T.]
[1077] Riley, _American Naturalist_, 1883, xvii.
[1078] Lahory, _Edin. Med. Journ._, 1856.
[1079] v. Frantzius, _Virchow’s Archiv_, 1868, xliii.
[1080] Lutz, _see_ Joseph, _Deutsch. med. Zeitg._, 1885.
[1081] Conil, _Annal. de Science nat. zool._, 1878.
[1082] [This fly belongs to the genus Cordylobia, and is peculiar to
Africa. _C. anthropophaga_, or the tumbri fly, is, when a larva, a
subcutaneous parasite of man and animals.--F. V. T.]
[1083] Delasiauve, Gerhardt’s “Handb. d. Kinderkrankh.,” 1878, iii.
[1084] Weber, _Mexique Rec. d. Mém. de Méd. milit._, 1867.
[1085] Mankiewicz, _Virchow’s Archiv_, 1868, xliv.
[1086] Kirschmann, _Wien. med. Wochenschr._, 1881.
[1087] Prima, “Thèse de Paris,” 1881.
[1088] Britton, Cambridge, Massachusetts, 1883.
[1089] Richardson, _Medical Monthly_, 1883.
[1090] Schmidt, _Texas Med. Journ._, 1887.
[1091] Wolinz, _Wratsch_, 1884.
[1092] Adler, _Med. Record_, 1885.
[1093] Curran, _Med. Press and Circ._, 1887.
[1094] Pierre, “Thèse de Paris,” 1888.
[1095] Douglas, _Kansas City Med. Index_, 1890.
The case observed by Summa[1096] was that of a man, aged 28, who
suffered from nasal obstruction, fœtor, epistaxis and pain in the nose.
Out of seven of the cases occurring at Fort Clark, U.S.A., and in its
neighbourhood, six ended fatally; in all these cases Kimball[1097]
diagnosed ozæna; attracted by the strong odour the flies forced their
way into the noses of the patients when asleep and there deposited
their ova. In a case reported by Carrière[1098] an abscess of the
nasal septum was produced by the larvæ of flies; Chiodi[1099] reports
seven cases of myiasis due to _Lucilia macellaria_; among these was
a case of rhinitis myiatica, in which a cerebral abscess leading to
a fatal termination developed, being produced by the migration of
a larva into the brain. Among the three cases of Lesbini[1100] was
that of a girl, aged 16, with 250 larvæ in the diseased nasal cavity.
Quintano[1101] observed larvæ beneath the eyelids in one case. It is
possible that the cases of Cesare[1102] and Calamida[1103] were those
of myiasis nasi due to _Lucilia macellaria_. The larvæ are also found
in the nasal accessory sinuses, as is seen from the cases reported by
De Saulle[1104] (frontal sinus), Delasiauve[1105] (frontal sinus),
MacGregor[1106] (antrum of Highmore), and Bordenave[1107] (antrum of
Highmore).
[1096] Summa, St. Louis, 1889.
[1097] Kimball, _New York Med. Journ._, 1893.
[1098] Carrière, _Gaz. hebd. de Méd. et de Chir._, 1898, xciv.
[1099] Chiodi, _La Argent. Med._, March 1, 1905.
[1100] Lesbini, _ibid._
[1101] Quintano, “Cronic oftalm. de Cadiz,” 1878.
[1102] Cesare, _Arch. ital. di Otol._, April, 1903.
[1103] Calamida, _Giorn. d. R. Accad. de Med. di Torino_, September,
1903.
[1104] De Saulle, _Gaz. des Hôp._, Paris, 1857.
[1105] Delasiauve, _Gaz. hebd. de Méd._, Paris, 1885.
[1106] MacGregor, _Arch. gén. de Med._, No. 1,031.
[1107] Bordenave, “Deuxième Mém. présenté à l’Acad. de Chir.,” v,
p. 387.
If a survey is made of the literature of the cases described of myiasis
nasi produced by _Lucilia macellaria_[1108] the following information
is forthcoming: In Europe this form of the disease is of very rare
occurrence, whilst in America and India[1109] it is frequent. Persons
suffering from ozæna are rendered the most liable to danger as the
penetrating odour entices the flies in tropical countries with intense
frequency, so much so that v. Frantzius does not consider this myiasis
as an independent disease, but as a complication of ozæna of frequent
occurrence in warm countries. The infection is so far of interest in
its nature, in that it only takes place during the day. The fly is on
the wing only by day when the sun is shining, and consequently only
deposits its eggs at this time. Therefore persons suffering from ozæna
are principally exposed to the danger of being pursued by the flies
when they succumb to sleep during the mid-day hours in the open or in
dwellings that are not closed up.
[1108] [And the other species, of course, must be included
here.--F. V. T.]
[1109] [Concerning Europe and India, _macellaria_ does not
occur.--F. V. T.]
Headache is the symptom which most troubles the patients. It extends
over the whole cranium and persists uninterruptedly, with more or less
severe periods. Violent headaches in the frontal and buccal regions are
almost always present in this complaint; they are experienced either
only on one side or on both simultaneously; sometimes the pain is
extended to the lower jaw and region of the neck, following the whole
extent of the trigeminal nerve. The inflammation of the nasal mucosa
produced by the penetration into it of the larvæ extends right into the
frontal sinus and antrum. Simultaneously the patients, at the height
of their trouble, suffer from persistent sleeplessness and severe
vertigo, so that they reel and cannot walk straight; excessive sneezing
always sets in at the commencement. The larvæ immediately spread over
the nasal mucosa to seek a place suitable to feed, and irritate the
nasal mucous membrane by the tickling sensation they produce. Later the
patients frequently sneeze when the maggots move to and fro.
One very characteristic symptom consists in the peculiar swelling of
the face, which is extended either over the whole or only one half of
it, and may alternate with attacks of erysipelas (Brokaw[1110]).
[1110] Brokaw, _see_ Seifert, in Heymann’s “Handb.,” p. 595.
The discharge from the nose is of special diagnostic value. It
consists of a blood-stained serous matter or blood-stained fluid,
which is perpetually trickling from one or both nostrils. The larvæ
especially choose the anterior portions of the nasal cavity, where they
can be seen lying in groups together at the base of the choanæ. The
consequence of this is that the soft palate becomes intensely swollen,
and this in turn makes swallowing very difficult; speech is impeded,
and the voice acquires a nasal intonation. Symptoms of fever become
more or less pronounced according to the number of larvæ present,
and according to the nature and constitution of the individual. The
appetite is in abeyance throughout the whole duration of the illness,
and sometimes there is the onset of slight attacks of diarrhœa.
If the larvæ are not removed in good time there follows excessive
destruction of the interior of the nose and of the turbinals; and the
whole nasal framework undergoes disintegration, frequently, too, the
velum palati, so that the larvæ come into sight in the oral cavity.
Individuals thus severely attacked succumb through exhaustion,
symptoms of meningitis (cerebral abscess) or septicæmia (Prima[1111]).
Twenty-one out of thirty-eight cases recorded (collected) by
Maillard[1112] died.
[1111] Prima, “Thèse de Paris,” 1881.
[1112] Maillard, “Thèse de Montpellier,” 1870.
The method of prophylaxis is self-evident from what has been stated.
On bright summer days neither the healthy nor those suffering from
diseases of the nose should sleep during the day-time in the open or in
public habitations; sufferers from nasal diseases should pay special
attention to this.
Treatment consists in the removal of the larvæ; this, however, is not
always easy.
With regard to the methods which have proved to be effectual in
the destruction of living larvæ and their expulsion from the nose,
strongly smelling and easily diluted fluids come first, such as
alcohol, eau-de-Cologne, and ether, which should kill the creatures
when injected into the nostrils. The earlier physicians, such as
Salzmann,[1113] Honold,[1114] and Henkel,[1115] have seen good
results from the use of these methods, whilst Mankiewicz[1116] and
Goldstein[1117] obtained no results whatever. Kimball’s[1118] careful
investigations have shown that a decoction of bitter herbs recommended
by Behrends[1119] (tansy, wormwood) have just as little effect as the
tobacco decoction employed by Boerhave[1120] and Kilgour.[1121] The
sternutatories employed by the older physicians are entirely neglected.
Delasiauve[1122] experienced good results from the inhalation of the
smoke of paper cigarettes, which were soaked with a solution of 2·0
pot. arsenic in 30·0 distilled water. Whilst, according to Kimball,
balsam of Peru had no effect on the larvæ, Mankiewicz succeeded in
removing the larvæ from the nose with the help of that drug. Turpentine
steam or mixtures of turpentine employed by Indian physicians have not
been very effectual according to Moore,[1123] Kimball and Goldstein.
Success has been attained in some cases by the use of insufflations
of calomel (Roura,[1124] Cerna,[1125] Schmidt[1126]) or of iodoform
(Pascal[1127]). Joseph[1128] recommends concentrated alum solution
being sniffed up into the nose as very effectual. Sublimate and
carbol solutions do not appear to be very successful (Kimball, Moore,
Goldstein), whilst benzine inhalations (Pierre[1129]) have shown better
results. Scheppegrell[1130] strongly recommends injections of oil which
kill the larvæ, while it is perfectly harmless to the nasal mucosa.
Cesare[1131] employed nasal lavages with solutions of salicylate of
soda with good results, and Calamida[1132] lavages with physiological
saline solution. Bresgen[1133] recommends the nose being cocainized
and the larvæ being removed with a pincette. Roorda-Smit[1134]
cocainized the nose, then insufflated calomel and plugged the nose with
a gauze tampon dusted with calomel. After two hours fifty-six larvæ
crawled out along the plug. Continuation of the treatment resulted in a
complete cure.
[1113] Salzmann, _see_ Tiedemann, Mannheim, 1844.
[1114] Honold, _ibid._
[1115] Henkel, _ibid._
[1116] Mankiewicz, _Virchow’s Archiv_, 1868, xliv.
[1117] Goldstein, _New York Med. Journ._, 1892.
[1118] Kimball, _ibid._, 1893.
[1119] Behrends, _see_ Tiedemann.
[1120] Boerhave, _ibid._
[1121] Kilgour, _ibid._
[1122] Delasiauve, _loc. cit._
[1123] Moore, _Chicago Med. Times_, 1893.
[1124] Roura, _Gaz. di San. milit._, 1884.
[1125] Cerna, _New York Med. Journ._, 1893.
[1126] Schmidt, _Texas Courier_, 1884.
[1127] Pascal, _Arch. d. Méd. milit._, 1895.
[1128] Joseph, _Deutsch. med. Zeitg._, 1885.
[1129] Pierre, “Thèse de Paris,” 1888.
[1130] Scheppegrell, _New York Med. Journ._, 1898.
[1131] Cesare, _loc. cit._
[1132] Calamida, _loc. cit._
[1133] Bresgen, Eulenburg’s “Real. Encyclopädie,” third edition.
[1134] Roorda-Smit, _Deutsch. med. Wochenschr._, 1906.
Injections of chloroform water (Jourdran[1135]) or chloroform
inhalations, or injections of pure chloroform into the nose, have
proved the most effectual (Goldstein,[1136] Osborn,[1137] Jourdran,
Durham,[1138] Jennings,[1139] Kimball,[1140] Mackenzie,[1141]
Oatmann,[1142] Zarniko,[1143] Antony,[1144] Folkes[1145]). Camphorated
carbolic solutions are very well spoken of: Grayson[1146] states that
these kill the larvæ immediately. Some authors have removed the larvæ
with forceps (Goldstein[1147]), others with pincettes; thus Brokaw
extracted 200 fragments with the forceps, Pascal eighty fragments with
the pincettes, and Wolinz[1148] also appears to have removed the larvæ
with forceps.
[1135] Jourdran, _Arch. de Méd. nav._, 1895.
[1136] Goldstein, _New York Med. Journ._, 1892.
[1137] Osborn, _Daniel’s Med. Journ._, 1891.
[1138] Durham, _Chicago Med. Times_, 1893.
[1139] Jennings, _Kansas City Med. Index_, 1890.
[1140] Kimball, _New York Med. Journ._, 1893.
[1141] Mackenzie, “Diseases of the Nose and Throat.”
[1142] Oatmann, _Med. Mirror_, February, 1894.
[1143] Zarniko, “Lehrb. d. Krankh. d. Nase.”
[1144] Antony, _Bull. Soc. méd. des Hôp. de Paris_, 1903.
[1145] Folkes, _New York Med. Record_, 1907.
[1146] Grayson, _St. Louis Med. and Surg. Journ._, 1891.
[1147] Goldstein, _New York Med. Journ._, 1892.
[1148] Wolinz, _Wratsch_, 1884.
Greater operative measures than these do not appear to have been
undertaken in latter days; yet Morgagni[1149] states that the army
surgeon, Cæsar Mogatus, at Bologna, first trephined the frontal sinus
and then extracted a “worm” from it.
[1149] Morgagni, _see_ Tiedemann.
Larvæ of other _Muscidæ_ have come under observation much more rarely
(Cheval[1150] [larvæ of _Galleria mellonella_[1151]], Bond,[1152]
Dumesnil[1153] [larvæ of _Piophila casei_]). Species of the genus
Scolopendra (_Myriapoda_), which all shun the light and seek their
food during the night--which consists of animal and vegetable
substances--frequently make their way into the nasal cavities of people
when asleep. They are found not only in the nose, but in the accessory
cavities. In the chapter on the “Parasites of the Nose”[1154] we have
collected striking instances, but we have omitted to mention the
observation made by Bertrand[1155] (Scolopendra in sinus maxillaris)
and that made by Bergmann[1156] (Scolopendra in sinus frontalis). In
the same chapter some remarks are made as to the occurrence in the nose
of earwigs, caterpillars, scorpions and termites, as well as of animals
which have not been identified.
[1150] Cheval, _Journ. de Méd. et de Chir._, 1893.
[1151] [This is the larva of a moth.--F. V. T.]
[1152] Bond, _Int. Zentralbl. f. Laryng._, 1896.
[1153] Dumesnil, _see_ Friedreich, “Die Krankh. d. Nase,” 1858.
[1154] Seifert, _see_ Heymann’s “Handb.”
[1155] Bertrand, _Soc. méd. de Bologne_, 1839.
[1156] Bergmann, _Korrespondenzbl. d. deutsch. Ges. f. Psych._,
Neuwied, 1859.
The larvæ that develop in the auditory meatus penetrate the membrana
tympani, destroy the middle ear and may produce meningitis and
intracranial suppurations. In one case Vesescu[1157] extracted seven
living larvæ from the ear with the aid of a thin pair of pincettes.
Köhler[1158] recommends the infusion of drops of ol. terebinth. to
destroy the larvæ, Quintano[1159] the insufflation of the following
powder: Oxid. hydrarg. rubr., sulfur., āā 1·0 grm., pulv. gi. arab.
8·0 grm.; Lesbini[1160] recommends tincture of iodine. In the case
reported by Henneberg[1161] the larvæ were those of _Lucilia cæsar_.
[1157] Vesescu, _Riv. stiintelor med._, February, 1906.
[1158] Köhler, _Monatsschr. f. Ohrenheilk._, 1885.
[1159] Quintano, _see_ Seifert, _loc. cit._
[1160] Lesbini, _La Argent. Med._, 1905.
[1161] Henneberg, _Berl. med. Ges._, February 18, 1903.
Eye affections due to _Lucilia macellaria_ are very uncommon; the
literature relating to the lesions of the eye produced by the larvæ of
flies has been collected in Kayser’s[1162] work. In the cases under the
observation of Schultz-Zeyden[1163] both the eyes of a female tramp
were destroyed, and quantities of larvæ were also found in the nasal
fossæ and in the ears.
[1162] Kayser, _Klin. Monatsbl. f. Augenheilk._, 1905.
[1163] Schultz-Zeyden, _Berl. klin. Wochenschr._, 1906.
The Lucilia is found relatively seldom on the cutaneous surface.
Henneberg’s[1164] case was that of a neglected girl, aged 20, in whom
countless larvæ (_L. cæsar_) were found in a plica polonica; after
the plica polonica had been removed the scalp was found to be covered
with a large quantity of ulcers which swarmed with larvæ, large and
small. The skin of the trunk was also much macerated and covered with
larvæ. Death resulted from sepsis; Westenhöffer[1165] remarks on this
case that a lesion of the head from which the patient had suffered
previously and the perpetual state of intoxication in which she was
had probably given rise to the lodgment of the fly larvæ. Whether
the communications made by Munk[1166] of maggots in the mouth relate
to Lucilia I do not know. Vesescu,[1167] in one case with extensive
ulceration and deep fistulæ in the skin, removed 176 larvæ with the
pincette. In Roorda-Smit’s[1168] case there were two ulcers in the
neck of a girl, aged 17, and larvæ appeared at their base. After
dusting with calomel and the application of a bandage the next day
fifty-two dead or half-dead larvæ came to light. Recovery took place.
Lesbini,[1169] in the case of an old lady, saw numerous larvæ in an
ulcer of the leg she was suffering from. Hector’s[1170] case appears to
have been one of myiasis cutanea provoked by Lucilia.
[1164] Henneberg, _Berl. med. Ges._, February 18, 1903.
[1165] Westenhöffer, _Verein f. innere Med._, Berlin, May 7, 1906.
[1166] Munk, _Wien. med. Presse_, xxi.
[1167] Vesescu, _loc. cit._
[1168] Roorda-Smit, _Deutsch. med. Wochenschr._, 1906.
[1169] Lesbini, _loc. cit._
[1170] Hector, _Lancet_, 1902.
The first exact observations of myiasis cutanea from _Sarcophaga
magnifica_ are due to Wohlfahrt,[1171] in whose honour
Portschinsky[1172] named this species of fly _S. wohlfahrti_.
Portschinsky ascertained that _S. wohlfahrti_ was not confined to man
as its sole host, but that several of our domestic animals, such as
cattle, horses, pigs, dogs and geese, were visited. In these animals
small wounds serve to entice the flies and to supply them with a
suitable site for the deposition of their eggs. The oral armature of
the young larvæ renders it easy for them to penetrate not only the
mucosa and cutaneous surface but also intact places in the submucous
connective tissue. In many localities more than half the herds have
proved to be infected by the flies. The fly only frequents open
spaces and never enters human dwellings, and is so timid that it
approaches man only during sleep; infection, therefore, takes place
only out of doors, in summer, in clear, warm weather, and only in such
individuals as sleep in the open air. Individuals are most exposed to
risk who suffer from catarrhs or inflammations, combined with purulent
secretions of the nasal cavity (ozæna), or otorrhœa, or ulcers in any
parts of the body accessible to the female fly.
[1171] Wohlfahrt, “De vermibus per nares excretis,” Norimbergae, 1770.
[1172] Portschinsky, “Norae Soc. entomolog. Rossicae,” 1875.
The frequency and intensity of the infection will be in inverse
proportion to the advance in civilization of the inhabitants, their
idea of cleanliness, their having timely medical aid and the chances
of their being rapidly attended to. On that account the majority of
cases of myiasis (Sarcophaga) are reported from Russia. The literature
of this kind of myiasis nasalis is not very extensive; in addition to
Wohlfahrt, Portschinsky and Joseph,[1173] there is a communication by
Gerstäcker,[1174] who found fifteen adult larvæ of _S. wohlfahrti_
in the nasal cavity of one man. The larvæ transmitted from Ordruf by
Dr. Thomas to Löw,[1175] in Vienna, which were discharged from the
nose of a woman, aged 71, suffering from ozæna, were recognized by
the well-known dipterologist Braun as belonging to _S. wohlfahrti_.
Among the cases reported by Joseph, one only affected the nose; it was
that of a peasant girl, aged 11, who had suffered from ozæna; she had
travelled on the open road and had there gone to sleep. Severe symptoms
set in and death followed under delirium. In making the _post-mortem_
it was found that the interior of the nose was extensively destroyed by
larvæ of _S. wohlfahrti_. Powell found Sarcophaga larvæ in two persons
who had slept in the open air; the larvæ were killed by injections of
chloroform and sublimate. Destruction of the eyes by _S. wohlfahrti_
has only been observed in a few cases; it is reported by Cloquet[1176]
that, in the case of a ragman who had lain some time in the fields,
both eyes were pierced by larvæ. On the outer skin the larvæ of _S.
wohlfahrti_ have been found more than once in inflammatory or festering
areas. Freund[1177] demonstrated that from a five year old child, which
had suffered for some time from an impetiginous eczema of the skin of
the head, from two suppurating abscess cavities which extended to the
periosteum, which was already affected, twenty-one living larvæ were
taken; rapid healing took place under antiseptic bandaging.
[1173] Joseph, _Deutsch. med. Zeitg._, 1885.
[1174] Gerstäcker, “Sitzungsberichte d. Ges. f. naturf. Freunde in
Berlin,” 1875.
[1175] Löw, _Wien. med. Wochenschr._, 1883, xxxi.
[1176] Cloquet, _see_ Schultz-Zehden, _loc. cit._
[1177] Freund, _Ges. f. innere Med. in Wien_, December 5, 1901; and
_Wien. med. Wochenschr._, 1910, li.
The small treatise by Balzer and Schimpff[1178] contains two new
observations on myiasis externa; in the one case an ulcer on a
man’s foot was full of larvæ, in the other case the head of a woman
showed numerous larvæ without the skin of the head being destroyed.
Brandt’s[1179] observation is interesting, for he found such larvæ in
the gums of a sick person.
[1178] Balzer and Schimpff, _Annal. de Derm. et de Syph._, 1902.
[1179] Brandt, _Wratsch_, 1888.
The impression which one obtains of the active movement of larvæ on
wounds is a strange and at the same time uncanny one. One finds that
the larvæ to obtain protection against the drying of the surface of the
abscess almost incessantly burrow with their heads, first contracting
and then expanding the body, which rises and falls, and keeping the
tail upwards. Owing to these movements producing irritation, increase
of inflammation may ultimately arise, causing erysipelas and cellulitis.
The treatment of myiasis nasalis caused by Sarcophaga is the same as
in myiasis caused by Lucilia, and in the other places where found it
is merely a question of the removal of the larvæ and the subsequent
proper treatment of the surface of the abscess. In Northern Nigeria
Lelean[1180] found _Auchmeromyia depressa_ to be the cause of myiasis
externa.[1181]
[1180] Lelean, _Brit. Med. Journ._, 1904.
[1181] [Numerous instances of attacks by Auchmeromyia are known and
referred to under that genus, pp. 593–4. The species referred to here
is not _depressa_, Walker.--F. V. T.]
The occurrence of Oestrid larvæ in a human being is very rare, at least
up till now myiasis oestrosa has been very seldom observed in man in
Europe. Whilst the hosts of the _Muscidæ_ comprise a considerable
number of warm-blooded animals, on which the larvæ develop, each
species of the _Oestridæ_ appears, on the other hand, to have a
definite host or some definite hosts of the class Mammalia. No species
of Oestrid is peculiar to man. Although in America, as well as in
Europe, _Oestrus hominis_ was spoken of up to the middle of the last
century, no such species exists.
But in both hemispheres, in America much more often than in Europe,
Oestrid larvæ have been found in man. In Florida, Mexico, New Granada,
Argentina, Brazil, Costa Rica and other districts, and especially where
large herds of cattle are kept, myiasis oestrosa has been observed
in shepherds, huntsmen and amongst the rural population. The larvæ
of _Hypoderma bovis_, according to the observations of Goudot,[1182]
occur as a parasite in man. Poilroux[1183] found larvæ of cavicolous
_Oestridæ_ in the nose of a man, aged 55. Amongst the species of warble
flies, whose larvæ are parasites in domestic animals and game in
Europe, reliable observers have found larvæ of two kinds, _Hypoderma
bovis_ and _Hypoderma diana_, also in man.[1184]
[1182] Goudot, _Annal. d. Sci. nat._, 1845.
[1183] Poilroux, _Journ de Méd., Chir._, etc., 1809.
[1184] [_Hypoderma linearis_ is frequently confused with _H.
bovis_.--F. V. T.]
The larvæ of _H. bovis_ have very seldom been observed in the nose. The
case quoted by Kirschmann,[1185] which was that of a peasant woman,
aged 50, who was suffering from ozæna, and in which violent attacks of
sneezing, epistaxis, pain in the forehead, and swelling of the face
were observed, is, according to Löw[1186] and Joseph,[1187] not an
Oestrid; Muscid larvæ were evidently the cause. By the injection of
diluted iron chloride solution seventy-nine larvæ were removed from the
nose. In the case reported by Razoux[1188] the species of larva is not
definitely known--at least, v. Frantzius[1189] did not consider them
Oestrid larvæ. Joseph does not definitely say that Oestrid larvæ were
the cause of a case which he quotes. He was sent a number of uninjured
larvæ of _Oestrus ovis_ ready to pupate, which were said to have been
expelled, during violent sneezing, from the nose of a peasant woman
who had suffered for six months from continuous frontal headache and
chronic nasal catarrh.
[1185] Kirschmann, _Wien. med. Wochenschr._, 1881.
[1186] Löw, _Wien. med. Wochenschr._, 1882.
[1187] Joseph, _Deutsch. med. Zeitg._, 1885.
[1188] Razoux, _Journ. de Méd., Chir._, etc., 1758.
[1189] v. Frantzius, _Virchow’s Archiv_, 1868, xliii.
The Oestrides prefer to use the surfaces of wounds on the skin of man
to lay their eggs, which develop into larvæ; but they often use their
ovipositors[1190] to make a fresh wound. In this case there arise in
the skin, and particularly in the subcutaneous connective tissue of
the neck, in the region of the shoulder, as well as in other parts of
the body painful, furuncle-like inflammations which are known under
the name of gad-fly boils. These boils may become the size of pigeons’
eggs; if several are together, they appear to form a connected tumour.
Each tumour is elastic and somewhat movable, and has an orifice through
which the larva breathes and discharges its excreta. At times these
turn to festers and gangrenous disintegrations, which may even cause
the loss of a limb. Wilms[1191] had the opportunity a few years ago of
observing a case of myiasis dermatosa oestrosa in Leipzig. The fistula
which led to the larva was slit open and the larva extracted. As a
notable characteristic of myiasis oestrosa Joseph states that the larvæ
grow very slowly. The flight time of the _Oestridæ_ is the hot summer
months.
[1190] [The Oestrides appear to lay their ova on the hair of animals.
They do not puncture the skin.--F. V. T.]
[1191] Wilms, _Deutsch. med. Wochenschr._, 1897.
Adams[1192] observed on the Isthmus of Panama a number of cases of a
skin disease which is caused by the larvæ of _Dermatobia noxialis_
(_Gusano-peludo-Muche_). The larvæ penetrate not only the skin but also
the mucous membrane of the pharynx and larynx, and from there proceed
through the tissue to the subcutaneous cellular tissue. The infection
seems to result from bathing.
[1192] Adams, _Journ. Amer. Med. Assoc._, 1904.
The study of “thimni,” a human myiasis caused by _Oestrus ovis_, by
Ed. and Et. Sergent,[1193] deals more with the zoology and with the
geographical distribution of this insect in North Africa than with the
clinical appearances of myiasis. [This paper deals with matters of
great interest, with important facts.--F. V. T.]
[1193] Ed. and Et. Sergent, _Annal. de l’Inst. Pasteur_, 1907.
The treatment consists in the removal of the larvæ (from the nose); in
Brazil it is the custom to drop tobacco juice into the boil in order to
kill the larvæ (Strauch[1194]).
[1194] Strauch, _Journ. of Cut. Dis._, 1906.
One is only justified in speaking of myiasis intestinalis when there
is no doubt that living fly maggots or flies themselves can be proved
to have been found in the fresh contents of the stomach or intestine
(Schlesinger and Weichselbaum[1195]). In the discussion of myiasis
intestinalis we give the evidence of Schlesinger and Weichselbaum, as
well as that of Wirsing,[1196] to which must be added a number of other
investigations.
[1195] Schlesinger and Weichselbaum, _Wien. klin. Wochenschr._, 1902, i.
[1196] Wirsing, _Zeitschr. f. klin. Med._, 1906, lx.
In a great number of acute cases apparently only the stomach was
affected, there being no signs in the intestine. In these cases sudden
illness is noticed, colic, sometimes unbearable pains in the region
of the stomach, pyrosis, vomiting or continuous intense inclination
to vomit, occasionally even with the mixture of blood. Frequently a
general feeling of malaise, twinges of pain in the muscles, and attacks
of giddiness were notified, very rarely fever. Generally all the
symptoms disappeared in a short time when the larvæ had been removed by
an act of vomiting or by washing out the stomach.
It is well to note that in the history of many cases the pains
preceding the expulsion of the larvæ are stated to be extremely violent.
Acute myiasis of the intestinal canal frequently runs a course without
special symptoms and is only an accidental condition; one has, however,
in such cases to guard against errors. The fæces may be deposited in
vessels or places where fly larvæ are in great numbers, or a subsequent
infection of the fæces with the eggs or larvæ of flies may have taken
place. Only when the inspection of the excrement immediately following
defæcation proves the presence of living larvæ, and when there were
certainly no fly larvæ in the vessel previously, can one speak of the
passing of fly larvæ from the intestine. More frequent than the cases
showing no special symptoms are those with pronounced disturbances in
the intestinal passage, obstruction or diarrhœa (also constipation
and diarrhœa alternately), violent and sometimes agonizing abdominal
pains (Pottiez[1197]), which preceded the evacuation of the larvæ and
subsided after their removal. General symptoms, like weakness, languor,
transitory vague pains, loss of appetite, sickness, rarely fever,
giddiness, attacks of faintness, epileptic attacks (Krause[1198])
are observed. In a few cases blood and pus have been noticed in the
evacuation of the bowels.
[1197] Pottiez, _Bull. de l’Acad. royale de Méd. de Belgique_, xv.
[1198] Krause, _Deutsch. med. Wochenschr._, 1886, xvii.
In the cases of chronic myiasis of the intestine the aspect of the
disease is dominated by the complex symptom of colitis mucosa.
The following features are noticeable, namely, the intermittent passing
of blood, the influence over the expulsion of the larvæ of mechanical
procedure (massaging of the abdomen), the duration of the process for
several years, the sometimes enormous number of insects contained in
the dejecta. Another clinically important factor is the passing of
the larvæ in batches. While for some time no larvæ may appear in the
stools, they may suddenly be ejected in great numbers, either because
the conditions of feeding are not suitable, or because medicaments
remove them from the intestine. The hæmorrhage is ascribed by
Schlesinger and Weichselbaum directly to lesions of the mucous membrane
caused by the larvæ; in the case reported by these writers there were
found shreds of tissue as well as pus in the stool. The pains occurring
spontaneously in the abdomen are at times influenced by position and
attitude of the body, often they were more violent after rest and after
evacuation of the bowels; often they were continuous, but in that case
less intense; pressure on the abdomen is generally little felt. The
condition of the blood was in two cases (Pasquale[1199] and Schlesinger
and Weichselbaum) a marked chlorotic one. The state of nutrition seems
almost always to suffer with prolongation of the disease, but in
Peiper’s[1200] cases this was not so. The condition of the appetite
was in some instances good, in others very bad. A frequent symptom is
headache of a migraine-like character and neuralgic pains in different
parts.
[1199] Pasquale, _Centralbl. f. Bakt._, 1891.
[1200] Peiper, “Fliegenlarv. als gelegentl. Parasiten d. Menschen,”
Berlin, 1900.
Schlesinger and Weichselbaum’s case shows that there are forms of
myiasis intestinalis which, after prolonged sickness, lead to death,
and that in consequence of the formation of intestinal abscesses
stricture of the intestine may arise from the subsequent formation of a
scar.
The question of the mode of infection is interesting; in this mouth,
nose and anus must be considered. The most frequent way is certainly
by means of food on which flies have laid their eggs, or which is
permeated with young maggots. This may be raw (especially grated)
meat, cheese, fruit, salad, milk, cabbage, cold farinaceous foods,
raspberries. When the stomach is affected, when the gastric juice has
lost acidity and power of digestion, the larvæ will be able to stay
and develop more easily. According to Csokor,[1201] if the eggs get
into the gastro-intestinal canal of man with the food, the delicate
stages of the young larvæ would certainly not survive the action of
the gastric juice. Salzmann[1202] assumed that the invasion occasionally
occurred through the rectum, the larvæ creeping into the anus while
the person is asleep. Wirsing accepts this method of infection for two
of his cases, where it was a question of the infection of an infant.
Salzmann[1202] reports a case where the maggots of _Anthomyia_[1203]
_scalaris_ were passed in great numbers from the urethra of an old
man. The patient had been catheterized on account of urethral stricture
and was probably infected with eggs or larvæ at the same time.
[1201] Csokor, _Wien. klin. Wochenschr._, 1901, p. 129.
[1202] Salzmann, _Württemberg. med. Korrespondenzbl._ 1883, liii.
[1203] [This is presumably _Homalomyia_ (_Fannia_)
_scalaris_.--F. V. T.]
The diagnosis of the affection is easy and sure, if living larvæ
are found in the contents of the stomach or in the stools, and if
contamination is out of the question.
The number of different species of flies whose larvæ are found in
myiasis intestinalis is considerable. The larvæ of species of Anthomyia
(_A. canicularis_,[1204] _A. scalaris_, _etc._), of _Sarcophaga
carnaria_ and _S. magnifica_ and of _Musca vomitoria_[1205] are
especially observed.
[1204] [This fly, common in houses, is known as _Homalomyia
canicularis_, and the next belongs to the same genus.--F. V. T.]
[1205] [This fly belongs to the genus _Calliphora_, not
_Musca_.--F. V. T.]
The prognosis is certainly generally favourable, but must be made
with some reserve in chronic cases, in view of the observations of
Schlesinger and Weichselbaum (intestinal stenosis).
The treatment must aim at removing the larvæ as soon as possible from
the digestive canal.
In cases of myiasis of the stomach, a thorough washing out of the
stomach (Joseph,[1206] Staniek[1207]) is to be preferred to emetics
used with success in individual instances; perhaps it would be
advisable to add menthol or thymol to the mixture.
[1206] Joseph, _Deutsch. med. Zeitg._, 1885 and 1887.
[1207] Staniek, _see_ Schlesinger and Weichselbaum, p. 47.
In myiasis of the intestine internal remedies and local treatment of
the intestine must be considered.
So far santonin seems to have proved to be the best remedy. In some
cases extract. filicis maris, calomel, semina cucurbitæ, naphthalene
0·1 to 0·5 (Peiper[1208]), infus. of Persian insect powder (5 in 200),
mineral waters, Carlsbad water, seem to have had good results.
[1208] Peiper, “Fliegenlarv. als gelegentl. Parasiten d. Menschen,”
Berlin, 1900.
For irrigation of the rectum, weak solutions of argentum nitricum,
tannin, thymol, gelatine, ol. ricini, naphthalene may be used. Wirsing
administered an aperient (Rurella compound liquorice powder) and a soap
enema after the passing of the first larvæ.
The principal thing is the prophylaxis, which must include the careful
protection of articles of food, on which flies may lay their eggs
(protection by glass dishes, tulle or fine wire nets). Fruit should not
be eaten before being washed or rubbed with a cloth.
*Gastricolous Oestridæ* (Creeping Disease).
Syn.: _Creeping eruption_; _Larva migrans_; _Hautmaulwurf_;
_Dermatomyiasis linearis migrans oestrosa_; _Hyponomoderma_;
_Dermatitis linearis migrans_; _Linea migrans_; _Epidermiditis
linearis migrans Wolossatik_; _Kriechkrankheit_; _Hautkratzschorf_;
_Myiase hypodermique_.
Under the name “creeping disease,” R. J. Lee[1209] has recorded a
peculiar affection of the skin in a three year old girl, which appeared
first in the form of pale red, thread-like irregular protuberances,
which seemed partly to become entwined on the right malleolus and had
spread without causing special disturbances to the abdomen. Dickinson,
Fox and Duckworth[1210] reported, in connection with this, that they
observed a growth of this red line of about 1 in. per diem. Since then
a number of similar cases have been reported which, without doubt, were
cases of larvæ creeping under the skin. Crocker[1211] saw such a case
in a two year old girl, the progress of the red line varying in one
night between 4 and 7-1/2 in. In Europe the first case was observed in
Vienna, by v. Neumann and Rille,[1212] also in a two year old girl.
[1209] R. J. Lee, _Journ. Clin. Soc. Lond._, November 27, 1874.
[1210] Dickinson, Fox and Duckworth, _ibid._, 1875.
[1211] Crocker, “Diseases of the Skin,” 1893; “Atlas of the Diseases of
the Skin.”
[1212] v. Neumann and Rille, _Wien. klin. Wochenschr._, 1895;
_Dermatologenkongr._, Graz, 1895.
v. Samson-Himmelstjerna,[1213] Sokoloff,[1214] Rawnitzky[1215] found
larvæ at the end of the tract, which had been recorded as larvæ of
Gastrophilus by Cholodowsky.[1216] According to Blanchard (_Arch. f.
Par._, 1901) the larvæ were those of _Hypoderma bovis_.
[1213] v. Samson-Himmelstjerna, _Wratsch_, 1895; _Arch. f. Derm. u.
Syph._, 1897.
[1214] Sokoloff, _Wratsch_, 1896.
[1215] Rawnitzky, _Derm. Zeitschr._, v, p. 704.
[1216] Cholodowsky, _Wratsch_, 1896.
How these larvæ get into the skin has not yet been definitely
ascertained; v. Samson is of the opinion that they usually obtain
access to man as larvæ, Stelwagon[1217] believes that the infection
generally occurs in a seaside watering place; a patient of
Ehrmann’s[1218] fell ill when he returned from the manœuvres, where he
had lain for some time on the ground. Here and there it is reported
that the eruption was preceded for a longer or shorter time by lesions
of the skin (incised wounds, furuncles, slight excoriations, v.
Harlingen[1219]).
[1217] Stelwagon, _Journ. Cut. Dis._, xxii, 8.
[1218] Ehrmann, _Wien. derm. Ges._, November 17, 1897.
[1219] v. Harlingen, _Amer. Journ. of Med. Sci._, 1902.
Twice it has been suggested that perhaps the parasites might come
from vineyard snails (Crocker, Lenglet and Delaunay[1220]), and it
is pointed out by v. Samson that in Russia the infection of peasants
who work in the fields was specially frequent. It is noticeable how
frequently the affection begins on uncovered parts of the body (face,
hands, arms); but that fact, on the whole, is not in conflict with the
statement (Kengsep[1221]) that the disease makes its first appearance
over the nates, because children often sit on the ground and play with
that part of their body uncovered. A case observed by us was that of an
elderly lady who did not do this and was properly clothed, yet showed
the typical lines of creeping disease on the nates, and asserted again
and again that she had the feeling as if a worm were creeping under her
skin.
[1220] Lenglet and Delaunay, _Annal. de Derm. et de Syph._, 1904.
[1221] Kengsep, _Derm. Centralbl._, 1906, vii.
The disease occurs in children as well as adults, so that age, sex and
calling offer no determining point etiologically.
The clinical symptoms of the disease consist in the sudden appearance
of itching and burning; if the cause is looked for one perceives a red
line, raised but little above the surface of the skin, with irregular
curves, never branched, but often entwined, broadening more or less
rapidly at one end (1 to 15 cm. in twenty-four hours). The larva can be
seen sometimes with a lens under pressure of the skin as a dark spot;
formations of pus, such as other larvæ produce, are not noticed; now
and again there is a formation of little vesicles (Hamburger,[1222] v.
Harlingen,[1223] Bruno,[1224] Ehrmann,[1225] Brodier and Fouquet,[1226]
Rawnitzky[1227]). It may happen that the parasite burrows through a
small region of the skin with many close curves for some time; on the
other hand, observations exist where it covered large tracts in a short
time. The itching and smarting cease in the place left by the larva,
so that the patients even in the shortest tract can point out at which
end the larva is, even if they have not watched the lengthening of the
tract. Very rarely the larva invades the mucous membrane of the mouth,
the nose, and the conjunctiva, proceeding from thence to the external
cutaneous area.
[1222] Hamburger, _Journ. of Cut. Dis._, 1904.
[1223] v. Harlingen, _loc. cit._
[1224] Bruno, v. Rille and Riecke, “Handb. d. Hautkrankh. v. Mraček.”
[1225] Ehrmann, _loc. cit._
[1226] Brodier and Fouquet, _Bull. de la Soc. franç. d. Derm._, 1904.
[1227] Rawnitzky, _loc. cit._
The localization of the affection is very varied; the primary seat
has been observed on the glutei muscles (Lee, Kengsep, Morris,[1228]
Rille, Seifert) and their surroundings (Stelwagon, Hamburger, Bruno),
on the lower extremities (Stelwagon, Lenglet and Delaunay, Hutchins,
Moorhead, Lee, Crocker, Schmid,[1229] v. Harlingen), on the upper
extremities (Samson, Meade and Freeman, Hutchins, Sokoloff, v.
Harlingen, Brodier and Fouquet, Shelmire,[1230] Stelwagon), on the face
(Sokoloff, Moorhead, Kumberg,[1231] Rawnitzky, Crocker, Boas[1232]),
on the neck (Sokoloff), and on the body (Ehrmann, Brodier and Fouquet,
Kaposi,[1233] Topsent[1234]).
[1228] Morris, _Brit. Journ. Derm._, 1896.
[1229] Schmid, _Verein der Aerzte in Steiermark_, February 12, 1900.
[1230] Shelmire, _Journ. Cut. Dis._, 1905.
[1231] Kumberg, _St. Petersb. med. Wochenschr._, 1898.
[1232] Boas, _Monatsh. f. prakt. Derm._, 1907, xliv.
[1233] Kaposi, _Wien. klin. Wochenschr._, 1898.
[1234] Topsent, _Arch. de Par._, 1901.
The duration of the affection varies very much; it varies between a few
hours and some years[1235]; several times a spontaneous recovery has
been reported.
[1235] [This is extremely unlikely, as the bots of Hypoderma only live
for nine or ten months at the most!--F. V. T.]
The diagnosis of the disease is not at all difficult owing to its
peculiar appearance.
The treatment can only consist in the removal or killing of the larvæ,
since one cannot rely on spontaneous recovery, even if it has occurred
in some cases. If one should succeed in locating the larva as a black
spot at the end of the tract, its removal by means of a needle is
the simplest method (Quortrup and Boas[1236]). In some instances a
cure has been successfully accomplished by excision of the active
end of the tract (v. Neumann and Rille, Schmid). In opposition to
this method, which not all patients will allow, the method practised
by Arab women (Rille and Riecke[1237]) of killing the worm with red
hot needles is quite rational. Shelmire[1238] used the electrolytic
needle for the destruction of the maggots, Stelwagon[1239] made use
of cataphoresis, by means of which he applied a sublimate solution,
afterwards cauterizing with a drop of nitric acid, as excision was
refused. Crocker[1240] and v. Harlingen[1241] injected small quantities
of carbolic acid; Moorhead[1242] by a single freezing of the skin with
ethyl chloride, attained a definite cessation of the attack at the
active end. Hutchins[1243] in one case made use of hypodermic injection
of a few drops of solution of cocaine and afterwards of 1 to 2 drops of
chloroform; in a second case of repeated applications of tincture of
iodide, as Lenglet and Delaunay[1244] did. v. Harlingen[1245] allayed
the affection in his first case by rubbing in sapo viridis and tar,
in Kensep’s[1246] case the cure seems to have been accomplished by an
ointment containing resorcin, in Meade and Freeman’s[1247] case by a 20
per cent. ichthyol paste. In our case we made exclusive use of Lassar’s
paste; within four weeks a cure resulted, probably spontaneously, since
one cannot ascribe any essential effect to this paste.
[1236] Quortrup and Boas, _Hospitalstid._, 1907.
[1237] Rille and Riecke, “Handb. d. Hautkrankh.,” v. Mraček, 1907, iv.
[1238] Shelmire, _loc. cit._
[1239] Stelwagon, _loc. cit._
[1240] Crocker, _loc. cit._
[1241] v. Harlingen, _loc. cit._
[1242] Moorhead, _Texas Med. News_, 1906.
[1243] Hutchins, _Journ. Cut. Dis._, 1906.
[1244] Lenglet and Delaunay, _loc. cit._
[1245] v. Harlingen, _loc. cit._
[1246] Kensep, _loc. cit._
[1247] Meade and Freeman, _Brit. Journ. Derm._, October, 1906.
APPENDIX ON PROTOZOOLOGY,
Comprising Notes on Recent Researches, Formulæ of some Culture Media,
and Brief Notes on General Protozoological Technique.
BY
H. B. FANTHAM, M.A., D.Sc.
I.--NOTES ON RECENT RESEARCHES.
Since the foregoing section on Protozoology was sent to press, certain
interesting observations and results have been published. Brief notes
on such, and some references thereto, are now added.
It is necessary, however, to remark that sometimes it is impossible
to give a precise or rigid definition to a genus of Protozoa, owing
to differences of opinion, to differences regarding nomenclature or
to incompleteness of knowledge. Such a lack of definition, while
inconvenient for the time being, is not unhopeful, as it directs
attention to the necessity for further work, which is inevitable in
such a relatively new and wide subject as protozoology. Thus, it may be
noted in illustration that Minchin, in 1912, in his text-book regarding
the genus _Entamœba_ writes: “The entozoic amœbæ are commonly placed
in a distinct genus, _Entamœba_, distinguished from the free-living
forms by little, however, except their habitat and the general (but not
invariable) absence of a contractile vacuole.”
*Differences between Entamœba histolytica and E. coli.*--In
continuation of the remarks on pp. 34 and 40, it may be added that
Lugol’s solution (iodine in aqueous potassium iodide solution) in fresh
specimens shows by brownish staining the presence of glycogen in the
vacuoles of _Entamœba coli_. Such a reaction is rarely or never given
by _E. histolytica_.
*Phagedænic Amœbæ.*--Carini and others record cases in which the skin
around an operation wound in connection with liver abscess became
gangrenous. Amœbæ, possibly _Entamœba histolytica_, were found therein
and may have been responsible for the gangreno-phagedænic action.
*Endamœba gingivalis* (_see_ pp. 43, 44).--Smith and Barrett,[1248]
after analysing the early literature, state (June, 1915) that
_Endamœba gingivalis_, Gros, 1849, is the correct name for the
following organisms: _E. buccalis_, Prowazek, 1904 (see p. 43); _Amœba
gingivalis_, Gros, 1849; _Amœba buccalis_, Steinberg, 1862, and _Amœba
dentalis_, Grassi, 1879. They conclude that _E. gingivalis_ is the
causal agent of pyorrhœa alveolaris, and that this disease responds to
treatment with emetine.
[1248] _Journ. of Parasitol._, i, p. 159.
*Entamœba kartulisi* (see p. 44), synonym _E. maxillaris_, Kartulis, is
considered to be _E. gingivalis_.
Smith and Barrett adopt the generic name _Endamœba_, Leidy, 1879 (_see_
footnote on p. 31, also p. 34). Leidy worked on _Endamœba blattæ_.
*Craigia and Craigiasis* (_see_ p. 45).--Barlow[1249] (May, 1915) found
_Craigia_ (_Paramœba_) _hominis_ in cases of chronic diarrhœa and mild
dysentery in Honduras. He also described a new species of _Craigia_
under the name of _C. migrans_. Fifty-six cases were studied, five of
which were due to _Craigia hominis_, the remainder to _C. migrans_. In
_C. migrans_, each flagellate, on attaining full development, becomes
an amœba without dividing. Each amœba encysts and produces a number of
flagellates which are somewhat like cercomonads. On the other hand, in
_C. hominis_ the flagellate form produces, by longitudinal fission,
several generations of flagellates before entering upon the amœbic
stage. The cysts of _C. migrans_ contain fewer “swarmers” (flagellulæ)
than those of _C. hominis_, but the “swarmers” are somewhat larger,
namely, 5 µ instead of 3 µ in diameter. Further, there is no accessory
nuclear body in _C. migrans_, but its flagellum stains more deeply than
that of _C. hominis_ and has a peculiar banded appearance.
[1249] _Amer. Journ. Trop. Dis. and Prevent. Med._, ii, p. 680.
*Human Trichomoniasis* (_see_ pp. 52–56).--Lynch[1250] (April and
May, 1915), working in Charleston, seems to favour the view that the
trichomonads found in the vagina, urethra, mouth, lungs and alimentary
tract are one and the same organism, and that these flagellates may
further excite already existing inflammatory conditions. He gives
detailed histories of cases of (_a_) infection of the vagina and gums,
and (_b_) intestinal infection manifested as intermittent attacks of
diarrhœa. The flagellates were found in catarrhal vaginal discharge,
in blood-stained scrapings from the gums (together with _Endamœba
buccalis_), and in stools after a purge of magnesium sulphate. The
parasites were tetratrichomonads (_see_ footnote, p. 53), that is, each
possessed four flagella anteriorly as well as an undulating membrane.
Lynch successfully infected rabbits from the cases and from cultures of
the parasite. Encysted trichomonads were seen in a patient’s stools,
in rabbits infected therefrom and in cultures. The culture medium used
was bouillon acidified with about 0·05 per cent. acetic acid and the
cultures were maintained at 30° C.
[1250] _Ibid._, p. 627; _New York Med. Journ._, May 1, 1915, ci, p. 886.
Trichomonads occur in the digestive tracts, for example, the cæca
of rats and mice (fig. 422). In man allied flagellates can occur in
similar situations, as well as in other parts of the intestine.
[Illustration: FIG. 422.--_Trichomonas_ from cæcum and gut of rat: _n_,
nucleus; _bl_, blepharoplast; _fl_, flagella; _ax_, axostyle; _m_,
undulating membrane; _b_, line of attachment of undulating membrane to
the body. × 2,000 approx. (Original.)]
Other trichomonad-like organisms have been recently described from
the fæces of man, more particularly from cases of chronic dysentery
in the tropics. Derrieu and Raynaud[1251] (July, 1914), working in
Algeria, found a flagellate possessing five free flagella anteriorly
and an undulating membrane apparently lateral. They named the parasite
_Hexamastix ardin-delteili_, but the generic name _Hexamastix_ is
pre-occupied. Chatterjee[1252] (January, 1915), working in India,
found probably the same flagellate and called it _Pentatrichomonas
bengalensis_.
[1251] _Bull. Soc. Path. Exot._, vii, p. 571.
[1252] _Ind. Med. Gaz._, l, p. 5.
*Chilomastix* (*Tetramitus*) *mesnili* (_see_ p. 57).--Alexeieff[1253]
(1914) now places the parasite originally called _Macrostoma mesnili_,
by Wenyon (1910), in the genus _Chilomastix_, Alexeieff. The
differential characters of the genera _Tetramitus_ and _Chilomastix_
are not especially well marked. According to Alexeieff, _Tetramitus_ is
characterized by four unequal flagella (which he figures anteriorly), a
ventral cytostome in the form of a linear cleft and a pulsatile vacuole
in front of the anterior nucleus. _Chilomastix_, according to the same
author, has three forwardly directed flagella and a fourth backwardly
directed one in the cytostome, which is well developed (fig. 423).
Some authors consider that the fourth flagellum forms the edge of an
undulating membrane in the cytostome.
[1253] _Zool. Anzeiger_, xliv, pp. 203, 206; and _ibid._, xxxix, p. 678.
Diagrams of _Chilomastix mesnili_ are given in fig. 423.
[Illustration: FIG. 423.--_Chilomastix_ (_Tetramitus_) _mesnili_. _a_,
_b_, _c_, flagellate forms; _d_, rounded or encysted form. × 2,500.
(Original.)]
*Giardia* (*Lamblia*) *intestinalis* (_see_ p. 57).--Alexeieff[1254]
(1914) considers that _Lamblia intestinalis_, Lambl, should be placed
in the genus _Giardia_, Kunstler, 1882. Bipartition occurs in the
encysted state. The axostyles persist in the quadrinucleate cyst.
[1254] _Zool. Anzeiger_, xliv, p. 210.
*Cercomonas hominis* (_see_ p. 61).--This parasite is considered by
some authors to be of a doubtful nature, as it is thought to have
been mistaken for deformed or incompletely observed _Trichomonas_ or
_Chilomastix_ or even _Lamblia_.
Wenyon[1255] (1910) described _Cercomonas longicauda_ from cultures
of human fæces. It is considered that the genus is very confused, and
the author points out that the tail flagellum has been overlooked. He
considers that the genus _Cercomonas_ should include flagellates with
an anterior blunt end from which arises a single long flagellum, and a
posterior tapering end also with a flagellum, which can be traced over
the surface of the body towards the insertion of the anterior flagellum.
[1255] _Quart. Journ. Micros. Sci._, lv, p. 241.
Another species, _Cercomonas parva_, has been found in cultures of
human fæces by Hartmann and Chagas[1256] (1910). It has a somewhat
different structure.
[1256] _Mem. Inst. Oswaldo Cruz_, ii, p. 67.
Further researches are necessary on the organisms variously referred to
the genus _Cercomonas_.
*Transmissive Phase of Trypanosomes in Vertebrates.*--In addition to
the general remarks on the morphology of trypanosomes set forth on
pp. 70 to 72, it may be noted that Woodcock[1257] (November, 1914)
states that, in certain cases, there is a definite transmissive phase
of a trypanosome in its vertebrate host. He quotes the work of Minchin
and himself on _T. noctuæ_ of the little owl, in which the transmissive
form is spindle-shaped and occurs in the bird’s peripheral blood during
the early summer months (_see_ p. 69). A similar phase occurs in _T.
fringillarum_, and Robertson[1258] has found that the short, stumpy
form of _T. gambiense_ is its transmissive phase in vertebrates.
[1257] _Arch. f. Protistenk._, xxxv, p. 197.
[1258] _Proc. Roy. Soc._, B, lxxxv, p. 527.
*Trypanosoma lewisi* (_see_ p. 88).--Brown (1914–15) has published some
interesting results on the potential pathogenicity of _T. lewisi._
*Blepharoplastless Trypanosomes* (_see_ p. 101).--Laveran[1259] (April,
1915) suggested a practical use of strains of blepharoplastless
trypanosomes produced by the action of drugs. He finds that tryposafrol
will also produce such strains, and remarks on blepharoplastless
strains of _T. evansi_ and _T. brucei_, which in the former case can
undergo 450 passages without reversion, and in the latter 273 passages.
He states that if it is desired to inoculate surra or nagana to Capridæ
or Bovidæ in order to produce immunity, use should be made of the
blepharoplastless races of the respective trypanosomes, which races
are a little less virulent than the corresponding normal ones. Also,
the immunity which follows from an infection due to blepharoplastless
_T. evansi_ or _T. brucei_ is only a little less complete than that
following infections from either of the respective normal strains.
[1259] _C. R. Acad. Sci._, clx, p. 543.
*The Experimental Introduction of certain Insect Flagellates
into various Vertebrates, and its bearing on the Evolution of
Leishmaniasis.*--In continuation of the remarks on pp. 103, 104,
and 112, further researches have been conducted on the introduction
into vertebrates of flagellates normally parasitic in insects. The
vertebrates became infected by inoculation with the flagellates or by
being fed on insects containing the protozoa. Fantham and Porter[1260]
(June, 1915) published the following results. Flagellates from
sanguivorous and non-sanguivorous insects were used, and cold-blooded
as well as warm-blooded vertebrates as hosts. The introduced protozoa
were pathogenic to the mammals, but not markedly so to the cold-blooded
vertebrates. _Herpetomonas jaculum_, _H. stratiomyiæ_, _H. pediculi_,
and _Crithidia gerridis_ (parasitic in certain waterbugs) proved
pathogenic to mice. A puppy was infected by way of the digestive tract
with _H. ctenocephali_. Frogs became infected with _H. jaculum_ and
with _C. gerridis_, toads and grass snakes with _H. jaculum_, lizards
with _C. gerridis_, and sticklebacks with _H. jaculum_. Second and
third passages of some of the parasites were obtained. The protozoa,
whether _Herpetomonas_ or _Crithidia_, were present in the vertebrate
hosts in either the non-flagellate or the flagellate form, or usually
both. They were more abundant in the internal organs of the hosts,
more particularly in the liver, spleen and bone-marrow. In all
experiments in which _C. gerridis_ was used the parasite invariably
retained the crithidial facies in the vertebrate host. No transition
to a trypanosome was ever seen. Infections in adult animals were not
so heavy as in the young ones, and the parasites were more virulent in
young hosts, as is the case with Mediterranean kala-azar in children.
[1260] _Proc. Camb. Philosoph. Soc._, xviii, p. 137; and _Annals Trop.
Med. and Parasitol._, ix, p. 335.
The mode of infection of the vertebrate in Nature seems to be
contaminative, either by its food or through an already existing
abrasion or puncture on the surface of its body. Cases in which the
flagellate-infected insects have been allowed to suck the blood of
vertebrates have proved negative up to the present. In areas where
leishmaniases are endemic, an examination should be made of all
insects and other invertebrates likely to come into contact with
men or dogs, or rats and mice (see below), in order to ascertain
if these invertebrates harbour herpetomonads. Preventive measures
should be directed against such invertebrates, especially arthropods.
Further, it is likely that certain vertebrates, such as reptiles and
amphibia (especially those that are insectivorous), may serve as
reservoirs of leishmaniases, or, as they should preferably be termed,
herpetomoniases. From such reservoirs the herpetomonads may reach
man by the agency of ectoparasites or flies, especially such as are
sanguivorous.
That vertebrates in Nature can harbour herpetomonads in their blood has
been shown by the work of Dutton and Todd (1903) on the herpetomonads
of Gambian mice, while the recently published investigations of
Fantham and Porter[1261] (June, 1915) on natural herpetomonads in
the blood of mice in England have shown that these rodents may be a
natural reservoir of herpetomoniasis. The origin of the infection of
mice is to be sought in a flagellate of an ectoparasite of the mouse,
very probably _Herpetomonas pattoni_ parasitic in various fleas, which
protozoön can adapt itself to life in the blood of mice. Herpetomonads
were also found naturally in the blood of birds by Sergent (1907).
Recently, Fantham and Porter have successfully infected birds with
herpetomonads experimentally.
[1261] _Parasitology_, viii, p. 128.
The significance of insect flagellates in relation to the evolution
of disease has recently been set forth by Fantham[1262] (June, 1915).
The deductions to be made from the occurrence of a herpetomonad stage
in _Leishmania_, especially in _L. tropica_, in man himself, and of
flagellate stages of the so-called _Histoplasma capsulatum_ in man are
fully discussed and correlated. It is pointed out that flagellosis of
plants (see p. 104) may possibly be connected with leishmaniasis. The
evolution of _Leishmania_ from flagellates of invertebrates is thus
traced and the way again indicated for preventive measures against
leishmaniasis, as first set forth by Dodds Price and Rogers.
[1262] _Annals Trop. Med. and Parasitol._, ix, p. 335.
Franchini and Mantovani (March, 1915) have successfully infected
rats and mice by inoculation or by feeding with _Herpetomonas muscæ
domesticæ_ obtained from flies and from cultures.
It is of great interest to note that the recent observations of Ed.
and Et. Sergent, Lemaire and Senevet[1263] (1914) have demonstrated
the presence of a herpetomonad flagellate in cultures of the blood
and organs of geckos obtained from areas in Algeria in which Oriental
sore, due to _L. tropica_, is prevalent. _Phlebotomus_ flies, which may
harbour a natural herpetomonad, feed on the geckos and on men. Hence
animals like geckos may possibly act as reservoirs of leishmaniasis.
Lindsay[1264] (1914) writes that the parasite of dermo-mucosal
leishmaniasis in Paraguay is believed by native sufferers to be
conserved in rattlesnakes, and spread by ticks or flies (_Simulium_)
feeding on the reptiles and transferring the parasite to man.
[1263] _Bull. Soc. Path. Exot._, vii, p. 577.
[1264] _Trans. Soc. Trop. Med. and Hyg._, vii, p. 259.
*The Transmission of Spirochæta duttoni* (_see_ p. 116).--It is
probable that _Ornithodorus savignyi_ acts as the transmitting agent of
_S. duttoni_ in places like Somaliland (Drake-Brockman, 1915).[1265]
[1265] _Ibid._, viii, p. 201.
*Spirochæta bronchialis* (_see_ p. 122).--The morphology and
life-history of _S. bronchialis_ have been investigated by
Fantham[1266] (July, 1915). From researches conducted in the
Anglo-Egyptian Sudan, he found that _S. bronchialis_ is an organism
presenting marked polymorphism, a feature that has only been determined
by the examination of numerous preparations from the deeper bronchial
regions of various patients.
[1266] _Annals Trop. Med. and Parasitol._, ix, p. 391.
_S. bronchialis_ varies in length from 5 µ to 27 µ, and its breadth
is about 0·2 µ to 0·6 µ. These variations are due to the processes of
growth and division. Many of the parasites measure either 14 µ to 16 µ
long, or 7 µ, to 9 µ, the latter resulting from transverse division
of the former. The ends show much variation in form, but approach the
acuminate type on the whole. The discrepancies in dimensions given by
the very few previous workers on the subject are probably the result of
the measurement of a limited number of parasites. All such sizes can
be found on some occasion during the progress of the disease, when a
larger number of spirochætes is examined.
The movements of _S. bronchialis_ are active, but of relatively short
duration, when it is removed from the body. The number of coils of the
spirochæte is rather an index of its rapidity of motion than a fixed
characteristic of the species.
The motile phase of _S. bronchialis_ is succeeded by one of granule
formation, the granules or coccoid bodies serving as a resting stage
from which new spirochætes are produced. The formation of coccoid
bodies and reproduction of spirochætes from them can be observed in
life.
_S. bronchialis_ is a species distinct from the spirochætes occurring
in the mouth. It differs from them in morphology, pathogenicity and in
staining reactions. It is not a developmental form of any bacterium,
and is an entity in itself.
The passage from man to man is effected most probably by means of
spirochætes, and especially coccoid bodies, that leave the body in
the spray with expired air and by way of the nasal secretions. Owing
to the fragility and short life of _S. bronchialis_ extracorporeally,
the resistant coccoid bodies in air, in dried sputum and dust, and
possibly also on the bodies of flies and other insects, are probably
instrumental in inducing attacks of bronchial spirochætosis in human
beings, especially those having a lowered bodily resistance, such as
occurs after a chill. Lurie (December, 1915), has described a case from
Serbia.
*The Spirochætes of the Human Mouth* (_see_ p. 122).--Two species of
spirochætes were recorded as occurring in the human mouth about forty
or fifty years ago. These are _Spirochæta buccalis_, Steinberg (often
ascribed to Cohn, 1875), and _S. dentium_, Miller (often attributed to
Koch, 1877).
The most recent work on _S. dentium_ and _S. buccalis_ is that of
Fantham[1267] (July, 1915), who observed the parasites ascribed to
Cohn and to Koch, these being the two common spirochætes seen in the
mouths of natives of the Sudan and of Europeans in England, as well as
the forms described and cultivated by recent investigators. Some of the
mouth spirochætes are not very active, but there is marked corkscrew
and boring movement, and they are flexible. Tangles or tomenta of these
mouth spirochætes are common. Internal structure is seen with some
difficulty, but in some specimens it can be determined, and chromatin
granules are then seen. Mühlens (1907) figured stained specimens of _S.
buccalis_ and _S. dentium_, in which chromatin-coloured granules were
distributed along the bodies of the organisms.
[1267] _Annals Trop. Med. and Parasitol._, ix, p. 402.
_S. dentium_ has tapering ends, and varies in length from 4 µ to 10 µ.
_S. dentium_ is rather like _Treponema pallidum_, and has been placed
by some workers--for example, Dobell--in the genus _Treponema_. It
has already been mentioned, on p. 128, that Noguchi cultivated three
species of _Treponema_ from the human mouth--namely, _T. macrodentium_,
_T. microdentium_, and _T. mucosum_, but they cannot be easily
distinguished morphologically, and so may appear to be biological
varieties of _S. dentium_.
_S. buccalis_ has somewhat rounded or bluntly acuminate ends and varies
in length from 9 µ to 22 µ. A slight membrane or crest may sometimes be
observed. _S. buccalis_ was found to be the predominant spirochæte in
the mouths of eight natives examined by Fantham in the Anglo-Egyptian
Sudan.
_S. buccalis_ and _S. dentium_ take up stains well and with
relative ease. Intracellular stages of the parasites are uncommon.
Multiplication by binary fission has also been observed. Coccoid bodies
or granule stages of the mouth spirochætes are formed, but appear to be
relatively few in number.
J. G. and D. Thomson[1268] (1914) have written an interesting paper
on various spirochætes occurring in the alimentary tract of man and
of some of the lower animals. They have also given a useful list of
references, and the work of some of the earlier authors is discussed in
the paper.
[1268] _Proc. Roy. Soc. Med._, vii, pt. 1, p. 47.
With regard to the general morphology of spirochætes, it may be noted
that the so-called axial fibre of Zuelzer is acknowledged to be
homologous with the membrane or crista of molluscan spirochætes.
*Coccidia in Cattle.*--Regarding the remarks on coccidiosis or “red
dysentery” in cattle on p. 147, it may be added that Schultz[1269]
(July, 1915) has found the malady among cattle in the Philippine
Islands. He states that some irregular or atypical cases of apparent
rinderpest are really due to coccidia. As has been pointed out by
Montgomery, rinderpest can be transmitted by blood inoculation,
while coccidiosis cannot be so transmitted, but may be diagnosed by
the microscope. These differences should be remembered as the two
diseases are often found to be associated and are difficult to separate
clinically. Coccidia have also been found in Australian cattle.
[1269] _Journ. Infect. Dis._, xvii, p. 95.
*The Hæmosporidia.*--It is likely that this order (_see_ p. 151) may be
soon abolished. Mesnil[1270] (April, 1915) considers that the grouping
of the three families, Plasmodiidæ (or Hæmamœbidæ), Hæmogregarinidæ
and Piroplasmidæ in the order Hæmosporidia is no longer possible,
because of the coccidian nature of the Hæmogregarines (_see_ p. 154).
The Coccidia are divisible into the Adeleidea and the Eimeridea
(_see_ p. 141). The Hæmogregarinidæ are allied to the former, and the
Plasmodiidæ to the latter. The Piroplasmidæ, until more is known of
their life-cycle in the invertebrate host, cannot be more definitely
placed.
[1270] _Bull. Soc. Path. Exot._, viii, p. 241.
*The Leucocytozoa of Birds.*--Regarding the statement, on p. 153,
that Laveran and França consider that avian leucocytozoa may inhabit
red blood cells, it may be added that França[1271] (April, 1915)
remarks that the action of the parasites on the red cells is very
rapid and very intense. The host cells become so altered that it is
difficult to recognize their true nature. He used very young birds in
his researches. Two shapes of host cell are considered, namely, those
with fusiform prolongations, and those which are rounded and without
such prolongations (_see_ p. 153). The movements and form of the
Leucocytozoa determine the shape of the host cell, as was pointed out
by Fantham[1272] in 1910.
[1271] _Ibid._, p. 229.
[1272] _Proc. Zool. Soc. Lond._, 1910, p. 694.
Schizogony of these parasites has been seen by França (1915) and by
Coles (1914), in addition to Fantham (1910), and to Moldovan (1913),
mentioned on p. 153. Schizogony may also take place in the lungs of
the host. The genus _Leucocytozoön_, established by Ziemann in 1898,
belongs to the family Hæmamœbidæ.
II.--FORMULÆ OF SOME CULTURE MEDIA.
(1) *Culture Media for growing Amœbæ.*--There has been much discussion
as to whether the true parasitic _Entamœbæ_ or _Endamœbæ_ can be
grown on culture media (_see_ p. 42). Undoubtedly certain free-living
amœbæ can be so grown, and it is considered that some of the earlier
researches on the so-called artificial growth of the dysenteric amœbæ
were really due to contaminations with free-living forms. The following
media are worthy of note:--
Musgrave and Clegg in 1904 devised a culture medium for amœbæ. The
organisms grown by them were probably not dysenteric amœbæ, as was
thought, but free-living forms. Phillips[1273] (1915) gives a slightly
modified formula of Musgrave and Clegg’s medium, thus:--
Agar-agar 2·5 grm.
Sodium chloride 0·05 "
Liebig’s beef extract 0·05 "
Normal sodium hydroxide 2·0 c.c.
Distilled water 100·0 "
[1273] “Amœbiasis and the Dysenteries,” p. 8.
Without clarifying, sterilize at 7 kilograms pressure per square
centimetre for about three-quarters of an hour. It should be neutral to
phenolphthalein.
Anna W. Williams[1274] (1911) described a medium consisting of fresh
tissue spread on agar plates for the culture of amœbæ. There are
three stages in the procedure: (1) obtaining living amœbæ free from
other living organisms; (2) obtaining sterile tissue; and (3) making
successive transplants of amœbæ and tissue, and showing that every
transplant is free from other living organisms. Each step requires
many controls. The essentials of the method may now be given. Remove
aseptically and rapidly the tissue required, such as brain, liver,
kidney, or spleen, from a freshly killed animal (guinea-pig, rabbit, or
dog). Put each tissue on a separate agar plate. Cut the selected tissue
into tiny pieces, and spread them over freshly made agar plates. Place
these plates in a thermostat at 36° C. for twenty-four hours to insure
sterility. Add the broken up tissue to the amœbæ, free from bacteria,
and maintain the cultures in thermostats, some at 36° C., and some
at 20° C. to 24° C. Emulsions of liver and brain in sterile neutral
glycerine may also be used. The freshly removed tissue serves as food
for the amœbæ.
[1274] _Journ. Med. Research_, xxv, p. 263; and _Proc. Soc. Exper.
Biol. and Med._, viii, p. 56.
The cultural amœbæ mentioned on p. 42 were grown on such media or
modifications thereof. One modified medium actually used was brain
tissue, to which blood was added from day to day, and an easily
assimilable bacterium (one of the influenza group of bacilli) was
present, which did not overgrow the medium at a temperature of 38° C.
Different conditions of food and of temperature produced morphological
variations in the cultural amœbæ.
Couret and J. Walker[1275] (1913) state that they have cultivated five
varieties of intestinal amœbæ, the associated bacteria having been
previously separated. They used a medium consisting of agar to which
sterile autolysed tissue had been added. The sterile tissue, such as
brain or liver, was kept in a sterile thermostat at a temperature of
40° C. for ten to twenty days. The surface of the agar should be broken
up before use, and the medium must not be too acid (not over 1·5 per
cent.). They consider that autolysed tissue is necessary for the growth
of Entamœbæ, and that naturally associated bacteria aid growth by
autolysing the tissues.
[1275] _Journ. Exper. Med._, xviii, p. 252.
(2) *Culture Media for the growth of Protozoa parasitic in the
Blood.*--MacNeal and Novy,[1276] in 1903, used a mixture of blood and
agar for the cultivation of trypanosomes such as _T. lewisi_ and _T.
brucei_. They employed varying proportions of the blood and agar, a
medium consisting of two parts of defibrinated rabbit’s blood mixed
with one part of agar being useful. The trypanosomes grew in the
water of condensation. Some of the authors’ earlier formulæ contained
different proportions of blood and agar with a little peptone, while
one of these media contained meat extract, agar, peptone, salt and
sodium carbonate. The temperature, like the proportion of blood and
agar, varied with the trypanosome investigated, but the optimum was
25° C.
[1276] _See Sleeping Sickness Bulletin_ (1909), i, No. 8, p. 287.
Mathis[1277] (1906) somewhat simplified the technique of Novy and
MacNeal. He collected the blood of a suitable animal, such as
rabbit, cow or dog, strict asepsis not being essential. The blood
was defibrinated in the ordinary way. One part of blood was added
to two parts of agar at 50° C. The mixture was sterilized several
times by heating to 75° C. or 100 ° C. Slopes were made and the water
of condensation was inoculated with a little blood containing the
trypanosomes. Blood may be obtained from a superficial vein or from the
heart.
[1277] _C. R. Soc. Biol._, lxi, p. 550.
_Novy-MacNeal-Nicolle or N. N. N. Medium._--In 1908 C. Nicolle[1278]
brought forward a modification of the Novy-MacNeal (N.N.) medium. The
formula is as follows:--
Agar 14 grm.
Sea salt 6 "
Water 900 "
[1278] _C. R. Acad. Sci._, cxlvi, p. 842.
Apparently pure sodium chloride can be substituted equally well for sea
salt. The mixture is placed in tubes and sterilized in an autoclave.
To each tube one-third of its volume of rabbit blood, taken by aseptic
puncture of the heart, is added. The salt agar is kept liquid at 45° C.
to 50° C. and the blood is added to the mixture. The culture medium
so prepared is maintained for five days at 37° C., and then for a few
days at room temperature. This medium was devised for the cultivation
of _Leishmania_ (_see_ p. 106), but trypanosomes may also be grown
thereon. Subsequently, Nicolle recommended the use of citrated rat’s
blood heated to 45° C. for half an hour, instead of defibrinated
rabbit’s blood. On such a medium, J. G. Thomson and Sinton[1279] (1912)
succeeded in growing _Trypanosoma gambiense_ and _T. rhodesiense_
(_see_ pp. 76, 83).
[1279] _Annals Trop. Med. and Parasitol._, vi, p. 331.