pig, dog, cat, and tiger. It is believed to enter the human body with drinking
water and is a parasite 8 to 16 mm. in length, 4 to 6 mm. in width
and 2 to 4 mm. in thickness. The most typical symptom of its pres-
ence is hagmoptysis which may be mistaken for a manifestation of pul-
monary tuberculosis; there is also an intermittent cough with sputum resem-
bling that of infectious pneumonia. Cerebral metastases may occur with
paroxysms of Jacksonian epilepsy. The eggs, which may be found in the
sputum, are dark brown, thick-shelled, operculated and are from 80 to 100
H long and from 40 to 60 n broad.
The prognosis of the condition depends upon the general condition and
852 PAHASITIC DISEASES.
age of the patient, the presence of compHcations, especially pulmonary tuber-
culosis, and the number of the parasites in the lungs.
Prevention of this condition may be accomplished by boiling drinking
water and destroying the ova in the sputum by disinfection.
Treatment is symptomatic.
Distom|asis of the Blood or Bilharziosis is the result of infection with the
blood fluke or Bilharzia hczmatobium (Schistosomum hczmatohium). This
organism is a narrow worm, the male being from 4 to 15 mm. long, while the
female, which is generally carried by the male in a gynsecophorous groove,
is longer, being about 20 mm. in length. The blood fluke is common in
Eg}'pt and other parts of Africa and is believed to effect entrance through the
skin of persons who bathe in the rivers in which it is present in great num-
bers, and upon drinking water or upon infected food such as edible water
plants.
The males with the females seek the bladder and rectum; the latter lay their
eggs in the tissues but these travel to other parts, some being discharged with
the urine and feeces while others which are retained produce irritation, and
connective tissue changes and sometimes vesical and rectal papiUomata; in
other instances they become the nuclei of calculi.
Symptoms. The blood flukes may cause no serious distiurbance, at times
being present for long periods without resulting harm; usually, however,
their presence is associated with perineal discomfort, vesical irritability,
pain on urination and bloody urine; when the parasites are harbored in the
rectum there is tenesmus with stools containing mucus and blood; rectal ulcer-
ations and papiUomata may result in marked infections. The ova may be
found in the discharges from both bladder and rectum.
Such complications as vesical and renal calculi, perinseal fistulse and peri-
urethral abscesses may occur. The loss of blood may result in a moderate
degree of anaemia. There is a distinct eosinophilia with a corresponding
diminution in the number of polymorphonuclear leucocytes in the blood.
The parasites may reach the portal and mesenteric veins but in these situa-
tions cause no especial symptoms although a thickening of the tissues about
the portal vessels (Glissonian cirrhosis) is said to occur at times.
The affection is chronic in its course and as stated may not resiilt in serious
damage. Upon the incidence of other infections, especially in children, the
symptoms may disappear.
Prevention of the entrance of the fluke into the body consists in avoiding
possibly infected water and food and not bathing in the rivers of infected
districts.
Treatment. The employment of the extract of male fern has been sug-
gested although there is no known method of destroying the parasites in
the blood. The heematuria, rectal and vesical inflammations, should receive
NEMATODES. 853
appropriate treatment and the other symptoms should be combated as they
arise.
Intestinal Distomiasis. A new variety of blood fluke, the schistosoma cattoi,
has lately been described, the eggs of which are smaller than those of schis-
tosoma hcematobium, brown in color and do not possess the typical spinous
extremity. This parasite is said to inhabit the blood-vessels of the digestive
tract and to cause intestinal ulceration. The ova are found in the stools of
the infected individual.
The fasciolopsis Buskii, the mesogonimus heterophyes and the gastro-
discus hominis may be found in the small intestine. The first and the last
occur in British India and the mesogonimus has been observed in Japan and
Egypt.
NEMATODES.
ASCARIASIS.
Ascaris Lumbricoides (the round or maw worm) is one of the most
common human parasites and is found in all parts of the world. Its habitat
is the small intestine. It is most frequently observed in the young but is not
rare in adults. Usually not more than six or eight are found in one host but
instances in which more than a himdred have occurred have been reported.
Its body is round, tapering at either end and is marked with transverse stria-
tions. It is yellowish or brownish in color; its diameter is about that of a
common goosequill, the male being from four to eight inches (10 to 20 cm.)
in length while the female is eight to twelve inches (20 to 30 cm.) long. At
the oral extremity the worm possesses three lips, each supplied with fine
denticulations, while the caudal end terminates conically, being curved ven-
trally in the male and straight in the female. The eggs are ellipsoidal in
shape 50 to 75 // by 40 to 58 pL, thick-shelled and covered with an albuminous
envelope; when found in the stools they are stained yellowish from the faecal
matter.
When discharged in the intestinal evacuations the ovum slowly develops
in water or moist earth and is taken into the body with food or drinking water;
the embryo, which has up to this time been enclosed by the envelope of the
egg, is now freed by the action of the juices of the alimentary tract and grows
to the adult stage within four or five weeks.
The parasites usually remain in the small intestine but may migrate. They
have been found in the vomitus, in the faeces, in the bile ducts and in the pan-
creatic duct. Collections of them may cause intestinal obstruction and they
may wander to the mouth, nasal passages, into the air passages when they may
cause asphyxia or. pulmonary gangrene, or into the eustachian tube and cause
854 PARASITIC DISEASES.
perforation of the tympanic membrane. They frequently migrate into the
rectum.
Symptoms. The ascarides may give rise to no suspicious manifestations
but their presence is usually associated with intestinal irritation and resulting
colicky pain, dyspepsia, nausea, vomiting and diarrhoea; reflex symptoms
such as restlessness, disturbed slumber, headache, vertigo and even epileptiform
and choreic attacks may be observed. Salivation, itching of the skin, especi-
ally at the nostrils, and anus, lachrymation, swelling of the lachrymal papillae,
dilatation of the pupils and mental disturbances may occur.
Complications referable to the presence of the parasite in imusual situations
have been noted. Among these are jaundice, due to bile duct obstruction,
intestinal obstruction and symptoms of asphyxia. The worms have been
found in perforative appendiceal and perinaeal abscessess and in inflamed
herniae.
The diagnosis can be positively made only by demonstrating the presence
of the worms themselves or by finding the ova in the faeces.
The prognosis is wholly favorable unless complications arise.
Treatment. Prevention consists in abstention from the use of possibly
contaminated food or water.
The most efficient anthelmintic in ascariasis is santonica which is preferably
administered in the form of santonin. It may be given in divided doses either
mixed with powered sugar or sprinkled upon bread and honey or jelly;
for a child of five years three doses of i grain (0.065) ^^^h at intervals of
four or five hours are usually sufficient. Lozenges containing santonin are
not to be commended for they often fail to dissolve. The bowels should be
freely evacuated by a saline cathartic or calomel shortly after the patient has
taken the final dose of the vermifuge or the latter may be given with
calomel, i grain (0.065) of santonin to i or 2 (0.065-0.13) of the mercurial.
Untoward effects such as yellow discoloration of the urine or yellow vision
(xanthopsia) may follow the use of santonin but they are neither permanent
nor serious.
Sodium santoninate should not be employed since most instances of san-
tonin poisoning have been due to this salt.
Spigelia is also a popular remedy for the round worm and is best employed
in the form of the unofficial fluidextract of spigelia and senna, the dose for an
adult being 2 to 4 drachms (8.0 to 15.0); for a child of two years ^ to i
drachm (2.0 to 4.0) should be prescribed.
Chenopodium is considered an excellent vermifuge in ascariasis and is
particularly indicated in the presence of intestinal inflammation since it not
only expels the worms but also appears to benefit the irritation in the alimen-
tary tract. The ordinary dosage of the oil of chenopodium is 3 minims
(0.2) which may be administered in capsules, emulsion or dropped upon lump
ASCARIASIS. 855
sugar. The dose is usually repeated three times a day before meals, for two
days, when a cathartic should be ordered.
Oxyuris Vennicularis (the pin-, thread-, or seat-worm) is a very common
parasite and one of almost universal distribution. It occurs most often in
children but adults are sometimes infected; large numbers are usually present.
The parasite very closely resembles a short bit of white thread, the male being
about I of an inch (5 mm.) long and the female about twice this length. The
oral extremity is supplied with a mouth possessing three retractile lips. The
tail tapers to a point. In color the worm is white. The eggs are oval, flat
upon one side, thin-sheUed and colorless and about 50 /i by 16 to 20 jj..
The oxyiuris inhabits the lower end of the ileum and the coecum. They
wander freely, more usually downward to the rectum or even into the vagina
but sometimes upward even as far as the stomach whence they may be vomited.
When large numbers are present in the intestine they may form balls with
the mucous secretion of the gut; they may be discharged with the faeces and
the irritation which they cause often produces a chronic catarrh of the colon.
Infection is believed to take place as follows : The ova with the developed
embryos inside are passed in the fasces and become scattered over vegetables
and fruit, which later are to be used as food, here they may remain for con-
siderable periods without perishing. The eggs also attach themselves to the
tissues and hairs about the anus and, being removed thence by the fingers of
the patient, may be transferred to his mouth or contaminate substances which
he may handle and thus infect other individuals. The possibility of the ova
being transferred from faeces to food by flies has also been suggested. Water is
said not to transmit the infection for the ova quickly perish in this medium.
After the ingestion of the eggs the worm reaches the adult stage in about two
' weeks.
Symptoms. The most characteristic and common of these is anal pruritus
which generally appears soon after the patient retires at night; at this time
the parasites migrate and often appear at the anal orifice. The itching is
often extreme and the irritation caused by the presence of the worms in the
intestine may result in the production of a catarrhal colitis with the exudation
of a considerable amount of mucus. The rectal irritation also causes anal
prolapse, frequency of urination, urinary incontinence, balanitis in the male
and vulvovaginitis in the female; the latter may also be produced directly
by the entrance of the parasites into the vagina. The genital irritation may
induce the habit of masturbation. Nervous manifestations are more rare
than with other species of intestinal parasites but chorea and convulsions
have been observed.
The diagnosis. The worms may be seen at the anus, to which attention
has been directed by the complaint of itching; they may also be found in the
faeces, in which the eggs are likewise present.
856 PAEASITIC DISEASES.
The prognosis under proper treatment is entirely favorable although the
condition is often obstinate.
Treatment. The parasites in the intestine above the rectum may be
destroyed by the means suggested for the round worm but the most effective
method of treatment is that by rectal enemata. Preliminary to the medicated
injection the rectum should be cleared of faecal matter and mucus by means
of an ertema of lukewarm water containing i drachm (4.0) of borax to the
pint (500.0). After the bowel has relieved itself of this solution an injection
consisting of ^ a pint (250.0) of i to 10,000 mercury bichloride in warm
water should be administered. The injection should be given through a
soft catheter passed high into the bowel and it should be retained as long
as possible. The procedure should be repeated every other night until the
parasites and their eggs have disappeared, an enema of saline solution (0.9
percent.) being given upon the alternate evening.
Cleanliness of the parts about the anus is an absolute essential, for no matter
how much care is exercised the patient is likely to contaminate his lingers
by scratching and despite our best endeavors will often reinfect himself
by transferring ova to his mouth. After each defaecation or even oftener the
anus and perinaeum should be sponged off vidth i to 10,000 mercury bichlo-
ride solution, the anal folds being separated by means of the fingers to insure
perfect contact of the solution to all parts. On retiring, the anus may be
anointed with a little mercurial ointment or an ointment composed of ij
drachms (6.0) of mercury bichloride to an ounce (30.0) of vaseline.
Injections, the patient being in the knee-chest position, of solutions of other
substances are often efficient; of these an infusion of quassia — ^ pint (250.0)
of the preparation, i to 100 with cold water, to avoid extraction of too
much of the bitter principle — is often employed. Infusion of asafcetida,
aloes or garlic, as well as mixtures containing tannic acid, vinegar, oil of
eucalyptus and camphor, may prove useful. An infusion of garlic, with large
amounts of this substance taken by mouth, may destroy the parasites after
the failure of the more ordinary means.
Ascaris Alata {ascaris canis, ascaris mystax or round worm of dogs and
cats) is a slender whitish or brownish parasite, the male from i to i^ inches
(40.0 to 60.0 mm.) long, the female about three times this length. The
tail is rolled into a spiral and upon either side of the head there is a wing-like
projection. The mouth possesses three denticulated lips. The ova are nearly
spherical and from 68 to 72 // in diameter. They are contained in a thin
albuminous envelope. The life-history of this parasite is analogous to that
of ascaris lumbricoides. The ascaris alata is only occasionally found in
man.
The symptoms and treatment are similar to those of the ordinary round
worm.
ASCARIASIS. 857
Trichocephalus Dispar (ascaris trichiura or whip- worm). This parasite
is about 2^ inches (4 to 5 cm.) in length and possesses a body of rather remark-
able form, the anterior two- thirds being extremely thin and hair-like, while
the posterior one-third is thick and in the male obtuse and rolled into a spiral;
in the female it is straight and terminates in a blunt conical point. The ova
are oval and dark brown, their long diameter being about 0.05 mm.
Great numbers of this worm are often found in the coecum and colon. It
is quite common in Europe but is infrequent in the United States. The
symptoms are not characteristic and even if the host harbors large numbers
of the parasite he may exhibit no suspicious manifestations although anaemia
and diarrhoea are sometimes associated with the presence of the worm. The
diagnosis may be made by finding the eggs in the faeces.
Eustrongylus Gigas (dicotophyme gigas) is one of the largest of the nemat-
odes, the male being about i foot (30 to 40 cm.) in length while the female
is about three times as long. Its color is reddish and the cephalic extremity
possesses a six-lipped orifice bearing papillae. The ova are elliptical, thick-
shelled and brown, their longer diameter being 64 to 68 fi. This parasite is
found in the dog and other animals; it is rare in man. Its habitat is the pelvis
of the kidney; as a result of its presence this structure becomes dilated and
the kidney may become reduced to a hydronephrotic sac in which the parasites
are found siirrounded by bloody urinous fluid. The presence of the worm
is demonstrable only upon autopsy. The diagnosis rests upon the demon-
stration of the eggs in the urine. The parasite can be removed by surgical
operation only. Up to the present time only one kidney has been found in-
volved in a single individual.
Anguillula Acetici (the vinegar eel) is said to have been found in the
urine but its presence is more probably due to the fact that a dirty bottle
has been used to collect this secretion. The anguillulina prutrefaciens or
onion anguillula, which lives in this vegetable, has been found in vomited
fluid.
Strongyloides Intestinalis. These are small nematodes which are com-
monly found in the faeces of the epidemic diarrhoea of tropical countries.
They probably have no especial influence in the causation of the affection
but when present in large numbers may keep up the intestinal irritation of a
dysentery due to other causes. The parasites infest all parts of the intestinal
tract and may force their way into the bile and pancreatic ducts. The worm
is frequently found in Indo-China, East India, Africa, Europe and South
America; it has been observed in the United States in a number of instances.
It causes no marked symptoms but, when present in large numbers, may
produce anaemia. Stool-disinfection is necessary as a preventive measure
and the worms may be destroyed by the administration of the extract of
male fern.
858 PARASITIC DISEASES.
Acanthocephala {thorn headed worm). One or two instances of human
infection by the gigantorhynchus or echinorhynchus gigas have been reported
as well as one of echinorhynchus moniliformis. In the intestine of the pig the
gigantorhynchus is common, the intermediate host being the cockchafer or
the June bug.
^ ANCHYLOSTOMIASIS.
Synonyms. Uncinariasis; Hook-worm Disease; Brick-maker's Anaemia;
Miner's Anaemia; Eg}'ptian Chlorosis.
etiology. The train of symptoms to which the term hook-worm disease
has been applied is the resiilt of infection -uath two tj^es of parasite, the
anchylostomum duodenale of the old world and the uncinaria Americana
of the western hemisphere. Hook-worm disease has been recognized since
the time of the ancient Eg}'ptian writers but its connection with the anchy-
lostomum diiodenale, which was discovered in Milan by Dubini in 1838, was
not proven until within comparatively recent years.
The hook-worm is generally distributed throughout tropical and subtropical
coimtries, being very common in Eg^-pt and frequent in the Philippines, Porto
Rico and in the mining regions of Germany, Austro-Himgar}' and England.
In the United States no authentic instances of uncinariasis were recognized
as such until 1893. In 1902, Stiles, to whom we owe great credit for his
work upon this subject, showed that the disease was very frequent in many
parts of the country and that to hook-worm infection most of the anaemia
which was so common in the Southern States was due. An anchylostomum,
the uncinaria Americatm, is the specific parasite.
Both the anchylostomum duodenale and the uncinaria Americana possess
the same general morphological characteristics. The male is about |- of an
inch (i cm.) in length while the female is slightly larger," being about ^ an inch
(12 to 15 mm.) long; the length of the foreign worm is slightly less than that
of the native variety. The anchylostomum duodefiale is whitish in color or
flecked with brown spots posteriorly if the intestine contains blood, there are
transverse striae. The body tapers toward the head which is curved upon
the dorsum in the form of a hook. The head is pro\ided with seven curved
teeth. The tail of the male is abruptly pointed while that of the female is
more tapering and finely pointed. The eggs are ovoid in shape, colorless
and thin shelled, their long diameter being from 50 to 60 [x.
The American hook-worm has no hook-like teeth upon the oral rim but is
supplied with a large ventral and smaller dorsal chitinous lip upon either side,
and a larger and more prominent dorsal conical tooth. The ova are similar
to those of anchylostoma duodenale but are larger being from 68 to 70 (x in
the longer diameter.
ANCHYLOSTOMIASIS. 859
The parasite inhabits the duodenum and jejunum; the eggs are passed in
the faeces and liberate their embryos in water or moist earth; these develop
into larvae which may live for an indefinite length of time in the mud or water,
to be iinally taken into the stomach upon drinking water, food which is con-
taminated by the dirt under the nails or upon the hands or with earth which
is deliberately eaten. In other instances the larvae may enter the body through
the skin and iinally reach the intestine where they develop into the adult
parasites, suck the blood from the intestinal wall, produce minute haemor-
rhages, and, presumably, produce a substance which acts as a poison. The
sucked blood provides nourishment for the worm and upon autopsy the
parasite is found embedded in the mucous or submucous wall of the intestine
and the intestinal lining shows ecchymoses open at the centre.
The infection is most frequent in rural districts where sand abounds and
in individuals who come into close contact with the damp earth, such as
miners, excavators, brick-makers, etc. Whites seem to be more prone to
severe infections than negroes and the most marked types of the disease
occiir in women and young persons. Several cases in one family are often
observed.
Symptoms. These may be obscure in the mild type of the infection; in
medium grades of the disease the anaemia is more or less marked and in the
extreme cases the affection is characterized by extreme anemia and cedema.
The period of incubation (the stage of the disease before the ova appear in
the stools) is from four to ten weeks and may be characterized by irritation
of the gastro-intestinal tract. In some regions where imcinariasis is common
the faces of a considerable proportion of the comparatively healthy children
contain ova.
In the advanced stages of the infection there is more or less lack of bodily
development; the skin is waxy white or yellowish; hair is present upon the
scalp but is not abimdant upon other parts; the breasts and external genitals
are poorly developed; the fades is anxious and sometimes oedematous; the
conjunctiva are pale and lachrymal secretion is often diminished; the mucous
membranes are of poor color and the tongue may be marked with purple
or brownish spots. The cardiac apex beat is often visible and there may be
cervical pulsation; the abdomen is prominent as a result of hepatic and splenic
enlargement and the presence of ascites. The extremities may be oedematous
and sluggish ulcers may be present. There is no characteristic febrile move-
ment, in fact, the temperature may be subnormal. Dyspnoea is not rare,
there may be palpitation and haemic murmurs are frequently audible. The
appetite may be either diminished or increased and there is often a desire for
unusual foods such as salt, pickles, coffee, sand or clay. Either constipation
or diarrhoea may be noted. Such nervous manifestations as headache, vertigo,
mental hebetude and stupidity are common. There is emaciation with marked
86o PARASITIC DISEASES.
musciilar weakness. The urine often contains albumin; casts are rarely
found.
The blood shows a varying degree of anaemia, both the hemoglobin and the
number of red corpuscles being diminished. The leucoc\i;es may be slightly
increased or diminished. An important characteristic is the presence of
eosinophile leucocytes. These are said to be found in over 90 percent,
of the cases.
The diagnosis is easily made by finding the ova in the faeces; if the micro-
scope is not available a very simple and accurate test may be performed as
follows: Place an ounce (30.0) of fresh faeces upon a piece of white blotting
paper and allow it to stand for twenty to sixty minutes; remove the fasces
and examine the color of the stained paper. In 80 percent, of the cases of
uncinariasis of medium or severe grade the stain is reddish-brown and sug-
gestive of blood. In making this test the presence of haemorrhoids should
be excluded. The occurrence of eosinophilia is an important diagnostic sign.