agents for this purpose than the acid, as they are very violent in
local destruction and their action is very difficult to limit. The use
of caustic potassa was last revived by Amussat, but failed to find
favor from his contemporaries, and soon fell into merited disuse. Van
Buren says: "From recent experience with the thermo-cautery of
Paquelin, I am disposed to regard it as more manageable than nitric
acid, and at least equally efficient." Allingham mentions favorably the
strong carbolic acid as a substitute for the nitric as an application
to vascular and granular surfaces. The reckless method employed by the
older surgeons of cutting off internal piles with the knife or with
scissors, without any precautions against bleeding, is merely mentioned
in condemnation. Usually no serious symptoms are to be expected after
operations for hemorrhoids, but to this general rule there are
exceptions. Morton knows of two consecutive cases of tetanus after this
operation performed in a hospital in this city, and both terminated
fatally. One of the most common occurrences after the ligation of piles
is retention of urine, generally lasting for a day or two and requiring
the use of the catheter.
HEMORRHAGE FROM THE RECTUM.--Bleeding from these parts is more usually
of a venous than an arterial character, but in some cases of
hemorrhoids the bleeding is either arterial or arterio-venous. The
latter occurs upon the detachment of a polypus, but not necessarily of
a polypoid growth. Arterial or mixed bleeding occurs in carcinoma and
in rodent ulcer, and also from the stumps of badly-occluded piles. In
cases of vicarious menstruation from the rectum the venous blood simply
oozes from the surface of the over-congested mucous membrane. This
condition should be readily diagnosed by the physical properties of the
blood and from the history of the patient. In almost all cases of
bleeding near the anus it will be possible to pick up the vessel or the
bleeding point on a tenaculum and ligate with silk, which is the most
satisfactory method to the surgeon. The rectum has been dragged down
with volsella forceps to apply a ligature to a point high up, but in
some of these cases the acupressure pin {927} with the twisted suture
will be found more convenient. Should hemorrhage occur after the
ligation of piles which cannot be checked by ligature, such as a
general oozing, pass all the ligatures through a hole made in the
centre of a small round sponge, then tie them across a piece of stick
(thus constructing a sort of tourniquet), and twist this around. Van
Buren cites a case in which a sudden laceration of the integument and
sphincter occurred during forcible dilatation in a case of hemorrhoids
in a very broken-down subject, with very copious hemorrhage. He passed
a sponge armed with a double ligature into the bowel, and, directing an
assistant to make traction upon the threads, the bleeding was checked.
Injecting ice-water and perchloride of iron into the rectum will often
check hemorrhage. Allingham prefers the persulphate of iron to any
other styptic for this purpose. Passing fragments of ice into the bowel
while holding a lump of ice upon the sacrum sometimes answers a good
purpose. In many cases of secondary hemorrhage from large venous
sinuses in a state of ulceration it will be impossible to ligate, and
the use of the ordinary styptics will be but the waste of valuable
time: the bowel must be tamponed as follows: Thread a strong silk
ligature through near the apex of a cone-shaped sponge, and bring it
back again, so that the apex of the sponge is held in a loop of thread.
Wet the sponge, squeeze it dry, and fill its meshes with ferric alum or
with persulphate of iron. Pass the left fore finger into the bowel, and
upon it push up the sponge, apex first, by means of a metal rod or any
other convenient body, fully five inches into the rectum. Now fill the
rectum below this with cotton-wool filled with the styptic. The bowel
having been completely filled, make traction upon the ligatures (thus
spreading out the bell-shaped sponge), while with the other hand push
up the packing. If this is carefully done no fear of bleeding need be
apprehended. In these cases the patient often suffers from collections
of flatus, which may be obviated at the time of packing by placing a
flexible catheter in the bowel and packing around it. These plugs
should remain for at least five or six days, and frequently eight or
ten days are none too long. The packing must then be picked carefully
away from the sponge. Agnew's rectal chemise answers the same purpose.
In describing its application he says: "Through the openings at the end
of the largest-sized gum catheter pass a strong silk thread; take three
square pieces of the material usually known as mosquito-netting,
placing them one on top of the other; at the centre of these squares or
pieces make an opening, and pass the catheter through it, securing the
two together by the threads. In applying the instrument the different
layers of the chemise must be moistened with water, and afterward well
filled with the persulphate of iron. It is then conducted some distance
into the rectum on a finger previously inserted; after which it is
expanded like a parachute by packing between the catheter and its hood
with long strips of lint thrust up on the end of a bougie until the
bowel is distended on every side. The catheter will serve to conduct
away the flatus, and when, after eight or ten days, its removal becomes
necessary, this is very easily effected by drawing out the ribbon-like
pieces of lint which were used as packing." Another method is to stuff
the bowel with fragments of sponge to which threads are tied, the ends
of which, protruding from the anus, facilitate their withdrawal. In
conjunction with these procedures the patient's pelvis should be
elevated. {928} After excision of portions of the mucous membrane the
risk of hemorrhage will be lessened by the surgeon introducing through
the edges of each incision a few fine sutures.
Enormous quantities of blood may escape into the bowel after operations
without any external symptom being apparent until the patient becomes
pallid and weak. In other cases the patient will complain of tenesmus
and desire to go to stool, or of a sensation of something trickling
into the bowel. Upon the recognition of these symptoms search should at
once be made for internal hemorrhage.
Rectal Alimentation.
Before taking leave of this very interesting class of diseases and of
their modes of treatment, it seems proper to introduce a few remarks
upon the subject of rectal alimentation, as it is now a well-recognized
and much-practised means of sustaining those whose stomachs are unequal
to the work which in health is so easily and unconsciously performed.
In the use of the lower bowel as an absorbent surface of alimentary
substances many failures have been reported, a fair proportion of
which, it is safe to infer, are due to the methods employed, to the
nutritive matters employed, and to the condition of the rectum at the
time. Firstly, as to the state of the rectum, it must be empty. Wait a
reasonable time, say an hour, after stool, so that the gut may be more
passive; have the patient in the recumbent posture; direct him to
resist tenesmus and to exert both the will and the muscular power to
retain the aliment. The syringe must be of hard rubber, must be
rectal-ended, and of the capacity of two fluidounces, and perfect in
action.
The preparation to be introduced, after being warmed to a temperature
of 98° or 99° F., should be very slowly injected with the syringe,
which should be also warmed and oiled. The enema must never exceed in
amount two fluidounces. If this be rejected, wait a reasonable time and
try again, using a less amount. If tenesmus proves an insurmountable
barrier to ordinary means, an opium suppository is to be introduced
three hours prior to another attempt. It has been suggested, inasmuch
as tenesmus is often relieved by the application of cold to the rectum,
to introduce the aliment in that state; but this method is open to the
objection that rectal digestion would be much less likely to take place
under this condition, as the bowel would then have thrown upon it the
additional work of warming up the substance prior to absorbing it.
The usual errors made in applying this means of sustaining the patient
are, that the injections are too large, are too rapidly introduced, and
are not of the proper temperature. Allowing an interval of eight hours
between the enemata would afford three in the twenty-four hours, which
method has been found to offer the best results. This must be
persevered in at regular daily intervals for the patient to derive its
full benefit, and there is reason to suppose that the nervous system
gets expectant of these daily hours of support, as it does in the case
of our ordinary meal-times. An examination of the well-formed daily
stools of patients thus sustained will prove how close the analogy is
between this and digestion proper.
{929} Next, as to the substances to be employed. The best of these are
milk, eggs, concentrated beef-extracts or beef or chicken peptones, and
brandy or whiskey of good quality. These substances may be combined in
various proportions to suit the individual requirements of the case. A
very good mixture for this purpose is two tablespoonfuls of milk, one
tablespoonful of whiskey, and an egg, using both the yelk and the
albumen. To this add a little salt. This should be well beaten up and
properly warmed.
It is well to persevere in the use of these enemata even though at
first most of them appear to be rejected, as after a time, the rectum
becoming accustomed to their presence, absorption or so-called rectal
digestion may take place. This form of alimentation should be kept in
reserve in a case of chronic illness until all other methods of
sustaining the patient prove insufficient to support life. It is not
contraindicated even in some cases of chronic diarrhoea with persistent
vomiting and loss of peptic function, advantage being taken of the
intervals between the evacuations to introduce a small and very
concentrated nutrient enema. In ordinary cases not complicated by
diarrhoea the most convenient times will be found to be about seven
o'clock in the morning, three in the afternoon, and eleven at night.
Wetherill suggests the possibility of forming with solid extract of
beef, pepsin, and pure suet a nutrient suppository which might be
retained and absorbed in some cases in which it has been found
impossible to retain the enemata. A very small addition of white wax,
he thinks, would keep these solid during warm weather; if not, the suet
might be replaced by ol. theobroma (as in ordinary suppositories),
which is probably as likely to be absorbed as the suet.
{930}
INTESTINAL WORMS.
BY JOSEPH LEIDY, M.D.
All animals, except in general the simple cell-forms constituting the
sub-kingdom of protozoa, under ordinary circumstances are more or less
liable to be infested with others, called parasites, which commonly
live at the expense of their hosts, frequently with little or no
inconvenience, but often causing discomfort and suffering even unto
death. Parasites are distinguished as external and internal, the two
being mostly of a widely different character. The former chiefly
pertain to the division of arthropoda, or animals with jointed limbs,
as exemplified by lice, fleas, and flies of the class of insects, mites
of the class of arachnides, and epizoans and isopods of the class of
crustaceans.
Internal parasites, from their usual habitation named entozoa, are
commonly observed in the intestines of animals, and hence their
distinction as intestinal worms. The name has proved to be appropriate,
for investigations have shown that most entozoa, observed from time to
time in other parts of the bodies of animals, pass part of their life
in the intestinal canal of the same or of some other animal.
By far the greater number of entozoa are peculiar animals, constituting
the chief part of the scolecides, an extensive group of the sub-kingdom
of vermes or worms. Of this group they comprise the orders of CESTODES,
or tape-worms; the ACANTHOCEPHALI, or thorn-headed worms; the
TREMATODES, or fluke-worms; and the greater portion of the NEMATODES,
or thread-worms. Many entozoa also belong to the protozoa, but these,
so far as relates to man in a medical point of view, appear
unimportant, and will therefore not here enter into consideration.
In the course of their life entozoa undergo changes of form and
condition, and pass these in different organs of the same or of
different animals, and it may be for a brief period externally or in a
non-parasitic state. In many instances, as in the tape-worms and the
fluke-worms, the transformations accompanying the changes are of so
extraordinary a character that until their life-history was
investigated the successive metamorphoses were viewed as distinct
animals. Mostly, the entozoa pass one stage of existence within the
intestine of some animal, and another stage in different organs of
other animals. Many, perhaps most species, in each stage are peculiar
to one or a few nearly-related animals, but others of the same kind
infest a number of different animals. The animals infested by the same
parasite may be remotely as well as nearly related. Thus the Tænia
saginata, or beef tape-worm, in the mature state lives in the small
intestine of man {931} only, but in its juvenile or larval condition in
the flesh meat of the ox. The Tænia elliptica, the common tape-worm of
the intestine of the dog, in the larval condition lives in the louse of
this animal. The liver-fluke, Distomum hepaticum, occasionally found in
the liver of man, but of common occurrence in the sheep, to which it
proves so destructive in the affection known as rot, in the juvenile
condition lives in a little fresh-water snail of the genus Lymneus. The
guinea-worm, Filaria medinensis, which in the mature state is found
beneath the skin of man, in the larval condition inhabits the minute
crustacean cyclops of stagnant waters.
As would be reasonably supposed, entozoa commonly gain access to their
hosts through the food and drink, though in the case of aquatic animals
they also obtain entrance directly through the integument from the
surrounding medium. So long as they remain in the intestinal canal they
may occasion little trouble or inconvenience. When they are numerous in
this position or proportionately large, according to their peculiar
nature they may produce more or less suffering and even the most
serious consequences. Generally, however, it is when they occupy other
positions, to which they have migrated from the intestine, that they
induce aggravated symptoms proportioned to their numbers and the nature
of the organs they infest.
Many species of entozoa have been discovered in man, and most of them
are peculiar in kind. Many are common, and, while some are widely
extended, others are more or less restricted to certain localities.
They are variable in their frequency, largely proportioned to the
prevalence of habits which are favorable to their transmission, and
which, though under control, are more or less disregarded. Some species
are so rare in their occurrence that they seem to be accidental, and
therefore of comparatively little interest to the physician.
In general, the frequency of occurrence of intestinal worms is
proportioned to the extent of use of uncooked or insufficiently cooked
meats, the drinking of unfiltered standing waters, uncleanly habits,
and the intimacy of association with domestic animals. It therefore
follows that important prophylactics against infection by parasites are
properly-cooked food, the use of spring or freely-running water or
filtered standing water, cleanly habits, and the avoidance of intimacy
with domestic animals.
The Cestodes, or Tape-worms.
Tape-worms in the mature condition inhabit the intestines of vertebrate
animals, and are usually conspicuous for their long, tape-like
appearance and jointed character. In the juvenile or larval state they
infest the various organs, except the interior of the intestinal canal,
of both vertebrates and invertebrates, and in this condition are so
diminutive and inconspicuous that until a comparatively recent period
they for the most part remained unnoticed, and when known their
relationship with the mature forms was not recognized.
The mature tape-worm, as ordinarily observed, is a long, soft, flat,
white worm, which from its resemblance has received its familiar name.
{932} It has a small head, succeeded by a short, more slender neck
gradually widening into the body, which is divided transversely into
segments. These, which are usually called joints or links, and also
named proglottides, are so many individuals, and finally become
separated to hold an independent existence. The tape-worm clings to the
mucous membrane of the intestine by its head, which is provided for the
purpose with suckers, and in many cases also with circlets of hooks.
The segments of the body are incessantly produced by gradual growth and
successive division of the neck, and as they enlarge they become more
distinct and develop within a bisexual generative apparatus for each.
The worm has neither mouth nor intestine, but is nourished by
imbibition from the surrounding liquid in which it lies constantly
bathed. A pair of longitudinal vessels commences in the head and
extends throughout the body, one on each side, and in some genera is
joined by a transverse vessel at the fore and back part of every
segment. The mature segments have no body-cavity, but are occupied with
a complex bisexual generative apparatus, which is self-impregnating.
Finally the uterus, usually much ramified, becomes especially
conspicuous through distension with eggs, and the rest of the organs
for the most part become atrophied. The ripe segments successively
detach themselves from those in advance, often singly and not
infrequently several linked together. In this condition, often in
lively movement, they are discharged with the feces, and thus commonly
render themselves obvious to their host. Subsequently they may continue
to live a brief period externally in a non-parasitic condition.
Ordinarily, in moist excrement, or in water or similar materials, they
will remain alive for several days.
After the discharge of the tape-worm segments, together with the eggs
which had been previously laid by the latter and those still contained
within them, any or all may be swallowed by animals feeding in places
where the infected excrement has been deposited. When the proglottides
and eggs are taken into the stomach they are digested and the embryos
or proscolices are liberated.
The embryo or proscolex of the tape-worm is a microscopic spherical or
oval body, provided at one pole with three pairs of divergent spicules,
by which it is enabled to penetrate the walls of the stomach or
intestine of its host. From these positions the embryo migrates either
directly or through the blood-vessels to some other organ, most
frequently the liver or the muscles. Having reached its destination, it
becomes fixed in position, and for a time remains comparatively
quiescent, but undergoes further development. The embryo loses its
spicules and is transformed into the larval form or scolex. In most
species of tape-worms the scolex is simple or individual in character,
and consists of a head like that of the parent or mature worm, with a
neck ending in a capacious cyst, within which the head and neck are
inverted. In this form the scolex is contained in a sac of connective
tissue induced by the presence of the parasite. Such sacs, frequently
observed imbedded in the flesh, liver, lungs, and other organs of
animals, are familiarly known as measles. In this condition the
scolices of certain tape-worms have long been known, but as their
relationship was not recognized, they were viewed as distinct species
of parasites and described as cysticerci. In other species of
tape-worms the scolex is of compound character; that is to say, the
embryo {933} in its further development gives rise to the production of
one or more groups of individuals in conjunction. The compound scolex
thus forms a sac or a group of sacs, the basis of hydatid tumors. These
occur of various sizes, even up to that of a child's head, and may
occupy any organ of the body. They consist of a spherical sac or group
of sacs, simple in character or containing others, ranging in size from
that of a mustard-seed to that of a marble, or larger to that of a
walnut, enclosed in an envelope of connective tissue induced by the
presence of the parasite. The sacs are filled with liquid, and have,
attached within or free and floating, or less frequently attached
without, variable numbers of little white grains, which on examination
with the microscope exhibit the same constitution as the simple scolex
above described. As in the case of the cysticerci of measles, the
scolices of hydatids have long been known, but as their relationship
with the mature forms was unrecognized until lately, they were regarded
as distinct parasites and described as echinococci and coenuri.
Sometimes the compound scolex fails in development further than the
production of the sacs, which then constitute the so-called
acephalocysts.
Measles with their occupants, when retained in the muscles or other
organs, ordinarily undergo no further development, but ultimately,
after some months to a year or two, undergo degradation. The larva or
scolex dies and atrophies; the measle degenerates, and often becomes
the focus of calcareous deposit, shrinks to a little cicatrix, and may
finally disappear. Of a more serious nature is the tape-worm embryo
which produces the hydatid tumor. With the increase of this,
proportioned to the production of sacs and scolices, it may become so
large as greatly to interfere with the function of the organ it
occupies, and according to the nature of this organ will be the gravity
of the affection.
When, however, the flesh or other parts of animals affected with
measles or hydatids containing active scolices are used as food in a
raw or insufficiently cooked state, the meats are digested in the
stomach and the scolices liberated to pursue their further development.
Passing into the small intestine, the active scolex everts its head
from its caudal sac, which atrophies and disappears, and the parasite
attaches itself to the mucous membrane, and rapidly develops and grows
into the conspicuous and familiar form of the adult tape-worm. The
duration of life of the latter while maintaining its position in the
intestine is uncertain, but under favorable circumstances it commonly
continues for years, and thus, with the incessant production of ripe
segments charged with eggs, it becomes a constant focus of infection.
* * * * *
Three species of tape-worm in the mature condition are common parasites
of man, living in the small intestine. They are the Tænia saginata,
Tænia solium, and Bothriocephalus latus.
* * * * *
TÆNIA SAGINATA.--SYNONYMS: Tænia mediocanellata; Beef tape-worm;
Unarmed tape-worm; Fat tape-worm.
Larval condition: Cysticercus saginata; Beef measle-worm.
This, which is now regarded as the most common tape-worm of man, is
named the beef tape-worm because it is derived from the beef used as
food. In the mature condition it lives only in the small intestine of
{934} man, and in the juvenile condition it lives in the ox. Its
frequency is proportioned to the prevalence of the custom of eating
beef in a raw or insufficiently cooked state, conjoined with the
careless habit of leaving human excrement in pastures where it is
accessible to cattle.