ASCARIS MYSTAX, the common round-worm of the cat and dog, has been reported as occasionally infesting man. It resembles the former species, but is much smaller, commonly from one to four inches in length, and has the head end furnished with a pair of lateral narrow, wing-like expansions of the integument. It inhabits the small intestine, and when present in man would no doubt induce symptoms like those of the ordinary round-worms which infest him.
TRIOCEPHALUS DISPAR.—SYNONYMS: Long thread-worm; Whip-worm.
The long thread-worm is a not unfrequent intestinal parasite of man, though rarely observed unless specially sought, as it ordinarily gives rise to little or no disturbance. It is common in England, Southern Europe, and the Orient. Davaine reports that half the cases of persons investigated in Paris were infested with it; it also occurs in this country. It inhabits the lower end of the ileum, the cæcum, and vermiform appendix, and feeds on the intestinal contents. It commonly occurs in small numbers, two or three to a dozen, occasions no evident inconvenience, and is rarely discharged with the evacuations.
The long thread-worm is yellowish-white and cylindrical, with the anterior half or more of the body attenuated in a hair-like manner. The female reaches about two inches in length, has the tail end conical, and the anus subterminal. The male is about two-thirds the length of the former, has the thicker portion of the body enrolled, and the tail end blunt. The eggs are laid in the intestine and discharged with the feces. The subsequent history of the parasite and its mode of infecting man remain unknown.
Only in cases where long thread-worms are numerous do they give rise to trouble. According to Leuckart, Pascal gives as constant symptoms of the presence of large numbers of the parasite, headache, redness of the face, prominence of the eyes, small, irregular, and intermittent pulse, and pains in the lower part of the abdomen.
The usual remedies addressed to the seat-worm and round-worm will most probably be equally applicable to the long thread-worm.
LEPTODERA STERCORALIS.—SYNONYMS: Anguillula stercoralis; Rhabditis stercoralis.
This is a minute nematode worm recently observed infesting French soldiers in Cochin China. It is about half a line in length, and inhabits the small and large intestine, and also penetrates into the biliary and pancreatic ducts. It occurs in myriads and occasions diarrhoea and dysentery. Another species, Leptodera intestinalis, nearly three times as large, has been noticed in smaller number associated with the former. The eggs of these worms are laid in the intestines, and both together are discharged in multitudes with the feces. They are probably introduced into man by drinking stagnant water, and undergo complete development after passing through the stomach.
It is probable that the remedies employed in the treatment of the familiar seat-worms and round-worms would be equally efficacious in the expulsion of these parasites.
ANCHYLOSTOMUM DUODENALE.—SYNONYMS: Strongylus duodenalis; Dochmius duodenalis; Sclerostoma duodenale.
This intestinal parasite, first noticed in Milan by Dubini in 1838, is of more dangerous character than any of the nematode worms previously described. In Europe, besides Italy, it was frequently observed among the workmen of the St. Gothard tunnel. It is exceedingly common in Egypt, and Bilharz found it in nearly all his post-mortem examinations of bodies. It probably prevails to a considerable extent in most tropical countries, including the East and West Indies and Brazil. There is also reason to suspect, from the nature of the affection it induces, that it may exist in the Southern States.
The Anchylostomum is a red, cylindrical worm, with the anterior extremity tapering and recurved. The head end, somewhat enlarged, encloses a capacious oral capsule armed with strong hook-like teeth. The caudal extremity of the female ends in a conical point, and the genital aperture is situated behind the middle of the body. The caudal extremity of the male ends in a trilobate pouch, within which projects the bispiculate penis. The female is from five lines to three-fourths of an inch long; the male is about half the size. The eggs are oval and measure 0.05 mm. long.
The worm inhabits the small intestine, especially the duodenum and jejunum, clinging tenaciously to the lining membrane by means of the armed mouth. It penetrates the mucous membrane to the submucous coat, from which it sucks the blood that forms its food. In the position of its attachment it gives rise to little ecchymoses. It often occurs in large numbers, even to hundreds and thousands. The eggs are laid in the intestine and are discharged with the evacuations. Externally, in water, the embryo undergoes development within the egg, and then escapes to lead for some time an independent existence. Subsequently, it is most probable that the worm obtains access to the human stomach by drinking standing water, and completes its development in the intestine.
The Anchylostomum proves to be a prolific source of wasting diseases in tropical countries, and is pernicious to an extent proportioned to the numbers infesting the intestine. By depriving the body of blood it produces a greater or less degree of anæmia. The affection begins very insidiously, and the general nutrition of the body may not be visibly disturbed until a late period. In moderate cases the disease is indicated by general paleness of the skin and mucous membranes, fatigue on slight exertion, and a tendency to palpitations and quickened pulse. In more severe cases there is constantly increasing debility, with increase of paleness, indisposition to exertion, excessive sleepiness, and feeling of coldness. Dyspeptic symptoms sometimes appear, and loss of appetite may alternate with ravenous hunger. Accompanying this there is often a disposition to eat innutritious articles, as coal, clay, wool, etc. Feeling of weight and oppression in the epigastrium and abdominal pains are frequent. In the advance of the affection shortness of breath appears, increased on exertion to violent dyspnoea. Emaciation becomes obvious in the later stage of the disease. In the worst cases the symptoms increase in severity, the patient becomes dropsical, is attacked with profuse diarrhoea and vomiting, and finally dies.
The severity of the affection is proportioned to the number of parasites present and the quantity of blood they consume and cause to be lost. Bad cases may end fatally in a few weeks, but generally the disease lasts for months, and where the patient is provided with abundance of good food it may continue for years.
The prognosis of the disease is rather unfavorable; if, however, the nature of the affection is ascertained before it has greatly exhausted the patient, and the parasites can be expelled, the result should be favorable.
We have thus far obtained but little information as to the best treatment for Anchylostomum. Calomel and turpentine have been recommended, and, as these are most powerful vermicides, we have reason to believe they would prove most effectual remedies.
In regard to the prophylaxis for Anchylostomum—and we may add in general for all parasites which gain entrance to man through drinking-water—all stagnant or standing waters should be filtered, so as to remove any source of infection, whether by eggs or free embryos of parasites or of larval forms existing within minute aquatic animals which serve as intermediate hosts to parasites. Standing waters, such as those of puddles, ditches, marshes, and ponds, more or less swarm with minute animals, all of which may be entirely removed by filtration. Even the water of cisterns and wells, if supplied from the free surface of the country, may not be free from minute animals, and especially eggs, and therefore requires filtration to be safe. Only spring and freely-running water of rivers and creeks and of lakes is commonly free from microscopic animals and their eggs, and therefore devoid of all danger in these respects.
STRONGYLUS LONGEVAGINATUS; S. bronchialis.—This nematode has been only once satisfactorily observed. Many occurred in the lungs of a boy in Germany, but the real cause of his death was not stated. The female worm is about an inch long, the male about five-eighths of an inch.
Certain worms previously discovered in the bronchial glands of a case of phthisis, and described under the name of Hamularia lymphatica, are regarded by Cobbold as the same with the former; but the descriptions of the two render this improbable. Treutler's drawing of Hamularia, as copied by Leuckart, looks like an Ascaris upside down.
EUSTRONGYLUS GIGAS; Strongylus gigas; Palisade-worm; Kidney-worm.—This worm, recorded in the catalogue of human parasites, is doubtful as such. Pertaining to the same family as Anchylostomum, as the common name indicates its usual habitation is the kidney. It is the largest of the nematodes, and is a long, cylindrical red worm, slightly tapering, and blunt at the ends. The mouth is enclosed by six rounded labial papillæ. The caudal extremity of the male ends in an inverted cup-like pouch, from which the penal spiculum protrudes. The female commonly ranges from one to three feet in length and from a fourth to nearly half an inch in thickness. The male ranges from six inches to a foot in length and from one to three lines in thickness.
The mature parasite is common in many fish-eating mammals, from which it is inferred that fishes are the intermediate host for the juvenile condition of the worm. It is frequent in the wolf, dog, mink, weasel, raccoon, otter, and seal. It also occurs in the hog, and is reported to have occurred in the horse, ox, and man. Usually it is solitary, and occupies one of the kidneys coiled upon itself. Under its influence the kidney is atrophied and reduced to the condition of a capsule of connective tissue, often containing bony spicules. It feeds on blood and on the purulent matter resulting from the inflammation it produces. The worm is occasionally found in other positions, as the mesentery, the abdominal cavity, the intestine, liver, urinary bladder, and lungs, but perhaps in most of these cases has been derived from its usual habitation. In this country the writer has repeatedly observed the kidney-worm in the mink, the dog, and the wolf. In one instance in the former animal he found a female and a male associated together in one kidney, which was reduced to the condition of a fibrous capsule containing in its wall a large radiated plate of bone.
The cases on record of the occurrence of this formidable parasite in man are of very early date, and are mostly doubtful as to the authentic nature of the worm, and are all unsatisfactory as to the attendant phenomena.
TRICHINA SPIRALIS.—The trichina, or flesh-worm, a minute nematode, is a common parasite of man, and from its wide prevalence and results may be regarded as the most dangerous of all. Perhaps from the earliest ages it has been dealing death freely and indiscriminately to our kind without its existence having been suspected until within the last half-century. Frequently, the affection, now named trichinosis, produced by its presence has been so prevalent in communities as to appear epidemic. The parasite was first discovered, and is commonly observed, as a little worm coiled up and imbedded in the flesh of man. In the same manner it is frequently seen in the flesh of the hog. In the adult or mature state it lives in the small intestine of both man and the hog, but its duration of life in this position is comparatively brief.
Trichinosis, or the disease induced by the introduction of trichinæ into the intestinal canal and the migration thence into the voluntary muscles, varies in symptoms and gravity with the number, condition, and position of the parasites and the susceptibility of the patient. The presence of trichinæ in the alimentary canal, though often accompanied by violent symptoms, is comparatively free from danger, whereas in the muscular system they not only produce the greatest suffering, but often the most disastrous results.
Man is ordinarily infected with the trichina by eating the raw or insufficiently cooked meat of the hog, or pork in any of its varieties of food. Infected meat often contains immense numbers of the parasite, a single ounce at times being estimated to contain from 50,000 to 100,000 worms.
The trichina was first distinctly noticed in the muscles of the human body by Paget in 1835, and was described by Owen with the name it now bears. It was subsequently observed under the same circumstances by other investigators. In 1846 the parasite was found by the writer in the muscles of the hog, but neither he nor others for some time afterward suspected the significance of the discovery. In 1860, Zenker of Dresden treated a supposed case of typhus complicated with excessive muscular pain and oedema. On post-mortem examination the muscles were found swarming with trichinæ, and to these the affection altogether was attributed. Nearly at the same time the investigations of Leuckart confirmed the relationship of the parasites as the cause of the disease. In 1862, Friederich first diagnosticated the affection and experimentally determined the presence of the worms in the living patient.
The trichina is also found infesting other animals of the same class besides man and the hog, especially the rat, mouse, rabbit, cat, and fox. Experiments further prove that mammals are generally more or less susceptible to infection with the parasite, though some appear to resist its extension to the muscular system, as in the case of the dog. The horse, ox, and sheep exhibit little disposition to artificial infection of the muscles, and hence from this circumstance and the nature of the food of these animals they are rarely found to be infested with trichinæ. In experiments on birds and lower classes of animals, though trichinæ were ascertained to advance in development in the intestine, they failed to invade the muscular system.
Ordinarily, it appears that while man is infected with trichinæ through the hog, this animal becomes infected by eating infested rats, mice, and cats, fragments of waste pork, and perhaps occasionally by feeding on the excrements of infested animals.
The trichinæ occupying the muscles are immature, and it is only after they are swallowed and the parasites are freed by digestion of the envelopes and pass into the intestine that they undergo development to sexual maturity. In this state the female is viviparous and gives birth to a multitude of active embryos, which immediately commence to migrate to the muscular system. As it is estimated that each female may give birth to upward of a thousand embryos, it is readily conceived to what an extent the body may become infested from eating a few ounces of trichinous pork.
The immature or larval trichinæ are also distinguished as muscular, and the sexually mature ones as intestinal, trichinæ, in accordance with their position in the two principal conditions.
Muscular trichinæ vary in condition from the embryo, which works its way among the muscular fibres or has obtained entrance into these, to the coiled-up worm lying quiescent in a capsule imbedded among the muscular fibres.
Infected flesh in the early state is scarcely distinguishable as such with the naked eye, but in old cases the trichina capsules become imbued with calcareous matter, and are thus rendered visible as minute white or grayish specks scattered through the red meat.
In the recent state of invasion the worms are found free among the muscular fibres or within these. Later, they appear mostly solitary and at rest, coiled within a fusiform mass of semi-liquid granular matter resulting from the degradation of the muscular substance. Subsequently, they become enclosed in an elliptical capsule, apparently derived from the myolemma of the muscular fibre they had entered. The capsules, situated among the bundles of sound muscular fibres, are arranged with their long diameter parallel with the latter. The trichina capsules commonly measure about one-fifth of a line long, and the coiled worm within is scarcely a half-line long.
If muscular trichinæ remain with their host, after a year or more they exhibit signs of decay. Commonly, little fat-globules appear at the poles of the capsules, and these become the seat of calcareous deposit. Finally, the worms die and undergo degeneration.
When meat with living trichina capsules is swallowed, the freed worms pass into the intestine, and here in the course of four or five days reach maturity.
The adult intestinal trichina is a minute, filiform white worm, thicker behind and tapering forward. The female is about an eighth of an inch long, and has the genital aperture at the anterior fourth of the body. The male is little more than half the length of the former, and has the caudal end provided with a pair of conical processes, between which is the genital aperture.
The ripe female trichinæ give birth to living embryos, and continue the function for about a month, after which they appear exhausted, ordinarily die, and disappear from the intestinal canal. The new-born embryos, about 1/200 of a line long, quickly leave the intestine to be disseminated throughout the body. Penetrating the mucous membrane, they probably enter the blood-vessels to be carried onward by the blood-currents, and perhaps also, in part, directly migrate to their destination in the muscles. The latter mode of progress is rendered the more probable from the circumstance that the muscles contiguous to the intestinal canal, as the diaphragm and those of the abdominal walls, are commonly most abundantly infested with the parasites. In the muscles of the limbs they are sometimes noticed to predominate toward the extremities of the former, as if retarded in their course by the tendinous connections.
It would appear that muscular trichinæ, to be capable of producing infection—that is to say, of further development—must have reached a certain stage, corresponding with the encapsulated condition, before they are swallowed. In this stage they may remain within their host probably for a year or two.
Children seem to suffer less in proportion to the quantity of trichinous meat they eat than adults, and they appear less susceptible to muscular invasion of the parasites. The difference is probably in a measure due to the greater susceptibility of the intestinal canal and the consequent production of more copious diarrhoea in children, with more complete expulsion of the worms.
SYMPTOMS.—In general, the effect produced by eating trichinous meat is proportioned to the number and condition of the trichinæ ingested and to the susceptibility of the patient. A few of the parasites may pursue their entire career and die within their host without ever exhibiting any obvious evidence of their presence. Sometimes the symptoms of trichinosis are obscure or trifling, sometimes sufficiently well marked, but moderate, and often they are more or less striking and violent. The period of incubation of the affection varies from a few hours to a week or more, and the duration of the disease also varies—both in a measure proportioned to the number and condition of the parasites.
In mild cases of trichinosis the patient may pass through the course of the disease without being confined to bed, and in a few weeks may be regarded as convalescent. The majority of cases pursue a slow course of from six or seven weeks to three or four months. A fatal termination is frequent, and is most common from the fourth to the sixth week, and appears mainly to be due to the loss of respiratory power. Fatal cases rarely happen after the seventh week.
From a few hours to a few days after eating trichinous meat the patient may be seized with dyspeptic symptoms—nausea, cardialgia, flatulence, eructations, and vomiting. These may be accompanied with complete loss of appetite, excessive thirst, bad taste, and fetid breath. There is also commonly a feeling of general uneasiness, with fulness of the forehead or headache, and feeling of weakness and fatigue to exhaustion or complete prostration. Neuralgic pains are felt in the abdomen and limbs, and the muscles generally are more or less relaxed and flabby.
Violent disturbance of the alimentary canal occurs only when large quantities of active trichinæ are taken with the food. The subsequent symptoms, due to invasion of the muscular system, may, but do not necessarily, accord in degree with the former.
Diarrhoea usually comes on early, and the evacuations, at first more consistent, become thin and clay-colored, like those of typhus or like the rice-water stools of cholera. In the severest cases the patient may die in this stage from extreme exhaustion and with all the appearance of cholera. Sometimes the diarrhoea subsides and gives place to obstinate constipation.
The muscular symptoms induced by the invasion of the trichinæ may be trifling or moderate, varying to a most violent character. They commonly appear after a week, and later up to the sixth week. The muscles become more or less swollen, hard and tender to the touch, or highly painful under pressure. Motion is extremely painful, and the patient usually lies in a helpless state with the limbs flexed—adults on the back, children on the side. Difficulty, with pain, in chewing and swallowing ensues, and even complete trismus, due to the presence of the parasites in the muscles of mastication and deglutition. Difficulty of breathing also arises from the presence of the trichinæ in the respiratory muscles, especially the diaphragm and those of the larynx. Even movement of the eyes is painful, due to the parasites in the orbital muscles. Bronchial catarrh comes on early, attended with hoarseness and asthmatic cough.
Fever may be absent in mild cases of trichinosis, but is considerable in the severer forms, though not in the first few days. The pulse accords with the increase of temperature.
Profuse sweating is a common symptom of the affection, commencing early and continuing throughout. Generally there is considerable decrease in the quantity of urine, which is highly colored.
Adults suffer with insomnia, while the reverse state prevails in children, who commonly lie in a soporose condition. Formication and dilatation of the pupils are frequent symptoms.
Oedema is a characteristic and pathognomonic symptom of trichinosis, and is seldom so slight as to escape attention. It commonly appears in the eyelids and face about the end of the first week, and may disappear after several days, to recur after several weeks. It usually commences in the limbs in the second week, and is more marked and persistent, and increases, especially in severe cases.
Peritoneal and pleuritic irritation and inflammation, with bronchitis and pneumonia, are not unfrequent complications in the more aggravated form of trichinosis.
Most cases of the disease reaching the seventh week advance in convalescence, while those of mild character by this time have recovered, except from the weakness and emaciation, which remain as evidences of serious illness.
Trichinosis in children is distinguished by greater mildness, less danger, abundant oedema, less muscular pain, a dormant condition, and more rapid convalescence.
The distinct recognition of trichinosis is difficult in isolated cases, but becomes more evident where it occurs in numbers, as in an entire family or in large portions of a community. The proof that the patient has partaken of trichinous pork helps to establish the diagnosis.
In the beginning of severe cases of the affection symptoms of a more or less violent gastro-intestinal catarrh are commonly present, often associated with slight fever and almost invariably excessive perspiration. Muscular lameness, both in mild and severe cases, is an early symptom. The disease is distinguished from cholera by the profuse perspiration and the peculiar muscular symptoms; from ordinary rheumatism by the gastro-intestinal catarrh and general exhaustion. With the appearance of oedema of the eyelids and face at the end of a week the diagnosis becomes more certain. The further progress of the affection is so characteristic that its distinction can scarcely remain in doubt. The general prostration, the violent muscular symptoms, the bronchial catarrh, the hoarseness and dyspnoea, the profuse sweating, and the sleeplessness, render the case pretty clear.
In the prognosis of the disease no positive conclusion can be derived from the severity or early appearance of the initial symptoms. Commonly, the more speedily they occur and the more violent they are, the less favorable will be the prognosis, while the later they appear, the more propitious it is. Long-continued diarrhoea is especially unfavorable, while a profuse diarrhoea at the beginning is to be viewed as a fortunate event. The prognosis is more favorable in cases in which sleep and the appetite are maintained, and in those in which the disturbance of the respiratory organs is slight. A favorable termination of the affection is the rule with children.
TREATMENT.—The treatment of trichinosis is not generally promising in favorable results. No means have yet been discovered to destroy or remove trichinæ which have migrated from the intestinal canal. While the parasites continue within the latter we may have reasonable hope of expelling them from the body by means of the usual remedies for intestinal worms. Experience, however, with these remedies has not been in accordance with expectations. In the mean time, until some more potent vermicide is discovered applicable to the destruction and removal of trichinæ from the intestine, we are disposed to place most reliance on such purgatives as oil of turpentine and castor oil and calomel and jalap. Subsequently, a good nutritive diet with wine is recommended to preserve the life of the patient until the affection has reached that period when the parasites become capsulated and there is no longer danger from them as irritants.
As a preventive of trichinosis, besides the avoidance of pork or its varied preparations of ham, sausages, etc. when it is known or suspected they may be infested, thorough cooking of meats is a certain means. A boiling temperature surely kills all animal parasites, but care is requisite that large pieces of meat should be cooked sufficiently long that the desired heat may extend to the interior throughout. The writer may add that it was in a slice of boiled ham, from which he had partly made his dinner, that he first discovered trichina in the hog.
Of the nematode worms there are many species of comparatively long, slender proportions, which constitute the family of Filaridæ. As parasites they rarely occupy the interior of the intestinal canal, except by way of transit, and live in most other organs and tissues of the body of both vertebrate and invertebrate animals.
FILARIA MEDINENSIS.—SYNONYMS: Dracunculus; D. medinensis; Medina-worm; Guinea-worm.
The Medina-worm has long been recognized as a parasite of man, and by competent authorities has been regarded as the fiery serpent which afflicted the children of Israel in the wilderness of Judea. It prevails in the tropical regions of Africa and Asia, and thence has been introduced into tropical America. It is ordinarily observed as a long, white, cord-like worm, situated beneath the skin in any part of the body, but mostly in the lower limbs, and especially in the vicinity of the ankle. Though a frequent parasite, only the female is known. In the mature condition it is nearly uniformly cylindrical, and ranges from eighteen inches to three or four feet in length and less than a line in thickness. The head end is rounded and furnished with a little papillate plate, in the centre of which is situated a minute oral aperture. The caudal end is conical and incurved. The intestinal canal is atrophied and without an anal aperture. The coelum is mainly occupied by a capacious uterus filled with free embryos. A generative aperture appears also to be absent, and the young can only escape by rupture of the parent.
Experiments made about a dozen years since in Turkestan by Fedschenko, at the suggestion of Leuckart, have shown that when the embryos of the Medina-worm are introduced into water containing the familiar little crustacean cyclops, they penetrate into this, and within it undergo transformation into the larval stage. The subsequent history of the larval worms remains unknown, but from what we have learned of the history of many parasitic worms it is reasonable to suppose that if the infested cyclops is swallowed in drinking-water, it may explain the presence of the mature worm in the human body. The young worms, liberated from their crustacean host by digestion in the stomach, probably enter the intestine, and thence migrate to their destination. In the young condition, advancing to maturity, the worms have been found in all parts of the body except within the cranium and eyeball. They appear to migrate in the course of the least-resisting connective tissues, along the route of the principal blood-vessels, until they reach the surface of the body.
Usually, a single worm is found in a person, though cases occur where several, to a dozen or more, are present. Commonly, the parasite is solitary, though two or three may be associated together. When deeply seated the Medina-worm ordinarily produces but little discomfort, though in some cases its movements are accompanied with more or less severe pain. It also gives rise to inflammation and the formation of an abscess, in the purulent matter of which the worm lies bathed. The removal of the worm, when accessible, by the proper surgical aid is followed by complete relief.
It is evident that filtration of the drinking-water would be a certain prophylaxis for the Medina-worm.
FILARIA SANGUINIS.—SYNONYMS: Filaria sanguinis hominis, Lewis; F. sanguinolenta; F. Bancrofti, Cobbold.
Another species of Filaria, a more dangerous parasite of man and indigenous to the tropics, is of frequent occurrence, though of comparatively recent discovery. It has been observed in India, Africa, Brazil, and the West Indies. It is commonly seen in the embryonic condition, living in the blood of patients affected with elephantiasis and certain other diseases, and is also found in the urine. In this early condition it is a minute worm, scarcely more than the 1/100 of an inch in length, and occurs together in immense numbers.
In the sexually mature condition the female filaria is a white hair-like worm three or four inches in length, living in the lymphatic vessels distally to the glands, especially in those of the lower limbs and scrotum. The embryos after leaving the parent pass into the lymphatic stream, and thence into the circulating blood. According to recent observations of Manson, they enter the blood in the evening and increase in number until midnight, after which they decrease and disappear by morning, from which time during the day they remain absent from the circulation. The investigations of the same authority have shown that when the blood of infected persons is sucked by mosquitoes these insects also imbibe the embryos, which subsequently undergo transformation in the mosquitoes into the larval state. In this condition the filariæ may be transferred to water, by drinking which man may become infected with the parasites. The larvæ introduced into the stomach appear thence to make their way to the lymphatics, within which they undergo further development to maturity, and thus remain a long time.
The presence of the worms in the lymphatics, with their numerous brood in the circulating blood, gives rise to hæmaturia and chyluria. As results of the obstruction of the lymphatic currents, the parasites induce inflammation, suppuration, lymphatic abscesses, buboes, lymphangiectasis, oedema, ascites, chylous hydrocele, elephantiasis,3 and certain cutaneous affections.
3 Several years since, with the view of ascertaining the presence of parasitic worms, the writer examined the blood of a case of elephantiasis under the charge of T. G. Morton, but none were detected. From what we have since been informed of the habits of Filaria sanguinis, the absence of the parasites may have its explanation in the circumstance that the blood examined was withdrawn in the daytime.
TREATMENT.—While the treatment of the affection induced by the Filaria sanguinis is varied and uncertain, the prophylactic measures are obvious and certain. Under favorable conditions of bright light, high temperature, and abundant food the stagnant waters of tropical countries are especially prolific of the minute forms of animals which harbor parasites. It hence becomes evident that all such waters, whether obtained from puddles, ponds, tanks, or cisterns, should be filtered before being used for drinking. Boiling is also effectual in destroying all the animal life of waters, and thus rendering them innocuous so far as parasites are concerned.
Several other species of Filaria have been found in the human body, but are little known and very rare in their occurrence.
FILARIA LOA.—This species occurs in Western Africa, on the Gaboon River, and is perhaps more frequent than now commonly supposed. It is an active worm, little more than an inch in length, and is usually found beneath the conjunctiva of the eye. It probably also occupies other positions, and a missionary on the Gaboon informed the writer that he had extracted one from the back of one of his own fingers. Its presence produced an intense burning pain. The negroes are reported to extract the worm by means of a thorn. The worm has also been observed in Brazil and the West Indies.
FILARIA RESTIFORMIS.—Under this name the writer recently described a large Filaria reported to have been withdrawn from the urethra of a man in West Virginia. It was obtained by C. L. Garnett, and sent, together with an account of the case, to the Army Medical Museum of Washington, where it is now preserved. It was a red cylindrical worm, twenty-six inches in length, tapering at the head, and thick, incurved, and obtusely rounded at the tail end.4
4 Proceedings of the Academy of Natural Sciences, Philada., 1880, p. 130.
FILARIA OCULI HUMANI; FILARIA LENTIS.—A few cases are on record of the occurrence of little worms in the aqueous humor and crystalline lens of the human eye, to which the accompanying names have been applied.
FILARIA TRACHEALIS.—Recently some minute worms found by Rainey in the trachea and lungs have been described under this name.
In conclusion, the writer acknowledges his indebtedness for much of the information of this article to the articles on "Intestinal Parasites" and "Diseases from Migratory Parasites" in Ziemssen's Cyclopædia of the Practice of Medicine, and to Glazier's Report on Trichina and Trichinosis.
DEFINITION.—The term biliousness is used to signify a disturbance of the gastro-intestinal digestion, with coincident excess in the production of bile. According to the popular conception, both lay and medical, the excess of bile is the cause of the symptoms; but when the whole subject is carefully examined it will be found that biliousness is made up of several factors, and that the hepatic disorder, if it exist at all, is a mere incident.
PATHOGENY.—From the time of Galen biliousness has been regarded as a morbid entity and the liver as the organ affected. Stoll, amongst moderns, first revived the Galenical doctrines. Abernethy1 was amongst English physicians the most conspicuous advocate of the condition called biliousness, and was the apostle of blue pill and black draught. Copland in his great dictionary2 more distinctly formulated the views of the English school—especially that portion of it influenced by the results of Indian practice—than had been previously attempted, and hence his work best represents the opinions and practice of the time amongst the English-speaking peoples. In this country the great Rush first promulgated the notions of biliousness which have since so dominated the medical opinion of this continent. A large part of the United States has proved a fruitful soil for the cultivation of theories of biliousness, since the condition known under this name is a frequent accompaniment of malarial poisoning. To this fact must be attributed the preponderating importance of biliary derangements in the practice of the physicians of India also.
1 Surgical Works, London, 1811, vol. i. p. 36.
2 A Dictionary of Practical Medicine, vol. ii. p. 723.
It is a fact which will be hereafter more fully developed that malarial infection may, and often does, derange the hepatic functions without producing fever. The malarial poison irritates the liver, and thus more bile is produced, but the quality deteriorates with the increase in quantity. The functions of the liver are more disturbed during an access of intermittent fever: the organ is swollen, the skin is muddy, the eyes yellow, the tongue coated with a thick yellow fur, and the urine is deeply tinged with bile-pigment.
Many of the metals employed as medicines and as poisons, as gold, silver, antimony, arsenic, phosphorus, etc., irritate the liver both in their entrance and in their exit from the organism, and cause biliousness; and the same fact is true of some vegetable alkaloids and animal poisons. The liver excretes many of these substances, and in their passage out from the blood the hepatic cells are irritated and an increased production of bile is a result. Improper food, indulgence in fats, sweets, condiments, and all kinds of fermented and alcoholic liquors, intestinal indigestion arising from any cause, and gastro-duodenal catarrh, are the most usual and obvious pathogenic factors. In respect to food and indigestion as etiological factors there are several points requiring more explicit statement. When nitrogenous elements (albuminoids) are in excess in quantity or as respects the power to digest and convert them, immature products, of which uric acid is the chief, accumulate in the blood. When the fats, sugars, and starches are in excess of the requirements of the organism or are imperfectly disposed of in the small intestines, a local irritation of the mucous membrane is produced, and various complicated, immature products enter the blood. With these troubles and faults of intestinal digestion a gastro-duodenal catarrh is usually associated. Without the production of catarrhal jaundice, gastro-duodenal catarrh, with the forms of indigestion accompanying it, keeps up a reflex irritation of the liver. Just as the presence of normal chyme induces the flow of bile, so the unhealthy products of intestinal indigestion excite an irritation of the liver. The continued operation of this cause maintains an abnormal activity of the liver, and more bile is produced than is easily disposed of.
SYMPTOMS.—The condition of biliousness, as now understood, is made up of derangement of the gastro-duodenal mucous membrane, with bile-production in excess and bile-absorption probably delayed. The symptoms are the product of these complicated conditions. The complexion is muddy; the conjunctivæ are yellow; the tongue is heavily coated with a yellowish-white fur; a bitter taste persists in the mouth; the breath is heavy in odor, even fetid; the appetite may be keen or there may be complete anorexia; a sensation of nausea, of heaviness, and fulness of the stomach is experienced, especially after eating; the bowels are confined usually, but occasionally the movements are relaxed, bilious in appearance, and cause heat and irritation about the anus; headache is constantly present to some extent, and there is a sense of fulness with more or less dizziness, and singing in the ears; vision is rather blurred, and there is a hebetude of mind; the urine is high-colored, high in specific gravity, and deposits lithates abundantly on cooling. When these symptoms are conjoined with hemicrania, nausea, and vomiting, the case is called bilious sick headache, and when diarrhoea supervenes, the discharges apparently containing much bile, it is bilious diarrhoea. The symptoms which above all others give the character to the morbid complexus are the muddy (bilious) complexion, the yellow-coated tongue, the yellow conjunctivæ, and the high-colored urine. The first departure from the normal may be scarcely observed. Gradually, owing chiefly to errors of diet, to climatic changes, or to malarial influences, or to these several factors combined, the affected person drifts into the condition of biliousness above described. Besides the general malaise, he experiences no little despondency, inaptitude for exertion, and indeed actual weakness. Finally, he is unable to apply himself to business, relinquishes the effort, and seeks advice.
COURSE, DURATION, AND TERMINATION.—Those who are accustomed to experience attacks of biliousness suffer from them at certain intervals which may be tolerably regular—at intervals of a few days, two, three, or four weeks—when the cause is uniform; but they may happen very irregularly when the conditions producing them are variable. The duration of an attack is from two days to a week or more, according to the severity of the symptoms and to the character of the measures instituted for relief. The termination is in a return to the normal state. If the conditions which produced it continue, when one attack is ended the preparations for another begin at once, and at length sufficient derangement of the organs concerned arises to constitute the morbid complexus of biliousness.
TREATMENT.—Prophylaxis has great importance, since the causes of the malady are to a considerable extent, at least, preventable. Errors of diet in respect to the use of condiments, fats, meat, pastry, etc. must be corrected. When there is pronounced gastro-duodenal catarrh and acid fermentation in the duodenum, the saccharine, fatty, and starchy elements of the food must rather be excluded and lean meats allowed. Abundant exercise, bathing, and an open-air life in general should be directed. Whenever a malarial infection is causative a change of climate becomes imperative. Heredity cannot, of course, be excluded, but the tendency to hepatic derangement can be rendered inoperative by an abstemious life.
The remedial management includes the dietetic as well as the medicinal treatment. When the distress has reached sufficient proportions to justify such an extreme measure, the patient should be restricted to a diet exclusively of skimmed milk, of which he is directed to take a gill or more every three hours. This serves a double purpose, as aliment and as a depurative agent, for this considerable quantity of fluid promotes the urinary excretion and the elimination of waste products. If the case is not severe enough to allow of such an expedient, the diet should in any event be restricted to skimmed milk hot, milk and hot water, hot lemonade, a little chicken or mutton broth, a bit of dry toast, etc. As a rule, although not so palatable, hot drinks are more beneficial than cold, but if the preference is decidedly for cold, they may be allowed. After the more severe symptoms have subsided a little lean meat broiled may be added, and as the cure proceeds the succulent vegetables and acid fruits may be permitted. Abstinence from potatoes, hominy, cracked wheat, and oatmeal should be enjoined during the convalescence of those who suffer from habitual attacks.
Medicines may not be necessary to those who have the resolution to adhere to skimmed milk for several days or who can abstain from food altogether for a day. Many experienced sufferers, especially through the South and West and in England, procure rather prompt relief from a blue pill of ten to fifteen grains or from one to five grains of calomel at night, followed by a Seidlitz powder, Rochelle or Epsom salts, or phosphate of soda on the following morning. Such patients find that no other treatment is as serviceable. They get relief from other measures, it is true, but neither as promptly nor as satisfactorily. It is held by the advocates of this practice that the mercurial acts on the liver—that the surplus bile is carried off; and they point to the peculiar stools and to the relief experienced in evidence of the truth of this theory. Without entering on the argument, which would occupy too much space, it must suffice here to state that calomel and blue pill do not increase bile-production,3 but they do stimulate the intestinal glands and increase excretion from them. The peculiar greenish stools produced by these mercurials do not owe their characteristic appearance to the presence of bile, but rather to the chemical transformations of the mercury itself and to the waste products excreted by the intestinal glands. Since the researches of Rutherford have been published, euonymin has been much prescribed in cases of biliousness. From three to five grains are taken at the bed-hour, and a mild laxative in the morning. In the same group of cholagogues are ipecac, iridin, sanguinarin, and especially podophyllin; but the serious objection to their use is that they stimulate the liver when this organ is in an irritable state. As calomel and blue pill have a sedative rather than a stimulant action on the liver, they are more useful in biliousness than are the true cholagogues. It should be borne in mind that one-half of a grain of calomel will have a distinct purgative action on many persons, and that one grain will rarely need to be exceeded.
3 That calomel, the type of a mercurial purgative, does not increase the discharge of bile has been demonstrated on dogs by Röhrig and Rutherford, and confirmed by observation of the effects of 20 grains on Westphalen's case of biliary fistula in man—a case in which, for a time, all the bile escaped externally, and none apparently entered the intestine (Deutsch. Archiv f. klin. Med., 1873, Band xi. pp. 598 and 600).
In general, notwithstanding the unquestionable utility of the mercurial, it is better to relieve cases of biliousness by less objectionable measures. A saline which acts at the same time on the intestines and kidneys, as Rochelle salts, is usually effective in bringing relief. A bottle of solution of magnesia citrate, of Saratoga water (Congress, Hathorn, or High Rock), and of Blue Lick, the famous sulphurous laxative of Kentucky, may remove the disorder in mild cases if at the same time a suitable diet is enjoined. Phosphate of soda in laxative doses, with or without Vichy water, is also a good remedy, if somewhat slow. The warm purgatives, rhubarb, colocynth, aloes, etc., are useful when there is pronounced constipation.