James M. (James Meschter) Anders.

A text-book of the practice of medicine online

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The latter states that he has " given this drug in larger doses than were
used in the case reported by Flint, and for a much longer period, with-
out the slightest effect upon the parasite."^ The adult filaria seems to be
beyond the reach of any known medication that will not prove dangerous.

( Guinea-worm Disease.)

The parasite is the filaria or dracunculus medinensis or persarum,
common in the tropics of Asia, Africa, and America. It is usually solitary,
and measures from 50 to 100 cm. (20 to 40 in.) in length and about 2 mm.
{-^ in.) in diameter. It is cylindric, whitish, with blunt papillated head,
and a sharp, curved tail. The body is nearly filled by the uterus, which
contains innumerable embryos, which, after maturation of the worm,
escape shortly after contact with water in the form of a milky fluid.
The process of emptying the uterus takes from two to three weeks. This
accomplished, the worm dies. It is then taken into the stomach and in-
1 British Med. Jour., June 2, 1894. 2 j/g^_ j^^y.^^ jyxay 2, 1896.


testines of man through the contaminated drinking-water. The female
enters the intestines by way of the mesentery and brings forth its young,
Avhich pass into the connective tissue of its human host. The male
Avorm is unknown. The worm has an inexplicable affinity for the sub-
cutaneous and intermuscular tissues of the feet and legs, where it attains
full development.

Symptoms. — Wherever the parasite is situated, it may often be felt
coiled up under the skin, which at tliat point becomes red and fluctuating
like an abscess. When opened, either surgically or naturally by the
worm, the head appears through the aperture. The favorite spot for
perforation is the dorsum of the foot, though sometimes it extrudes from
the legs, rarely the thighs, and vei'y rarely from the thorax and abdomen.

Treatment. — Prophylaxis in regard to the drinking-water and as to
bathing where the intermediary host of the dracunculus — the cyclops —
has its habitat is essential for safety.

The treatment embraces the surgical measures necessary to remove
the worm and to promote the healing of the irritated tissues. Roth claims
that after incision the application of carbolic acid (1 : 15) causes the worm
to be removed in two or three days. Native Indian physicians commend
highly the local application of the leaves of the " amarpattee " plant.


Among other filarige that have been found in man are the following :
The filaria imynitis, which causes hematuria and has been found in the por-
tal vein, whilst the ova were discovered in the ureteral and vesical walls ;
filaria lahialis, found in a lip pustule ; fila?'ia lentis, found in a cataract ;
filaria traehealis and bronchialis, seen in the trachea, bronchioles, and
lungs ; filaria hominis oris, observed by Leidy in the mouth of a child ;
filaria loa, noticed in the tropics among negroes, its habitat being beneath
the conjunctiva. Recently L. N. Boston found filaria mermus (ac-
cording to Wardell Stiles, to whom he referred them) in a cavity in
the centre of an apple. They are believed to be parasites of the apple
worm, but whether pathogenic, is not known.


Eustrongylus Gigas. — This parasite is exceedingly rare in man, but
has been found in many of the carnivora and in some herbivora. It is
supposed that fish act as the intermediary host for the larvae. The worm
is enormous in size, the female being from 25 to 100 cm. (10 to 40 in.)
in length. It is a red, cylindric parasite with blunt-pointed ends. Its
seat is the kidney, which it may destroy, causing hematuria and the
presence of the eustrongylus ova. Dr. John McKenna has recovered an
adult eustrongylus from a child whose urine had long contained ova.

Anguillula stercoralis or strongyloides intestinalis occurs in the stools
of certain tropical endemic diarrheas. It is common along the Gulf of
Mexico. The parasites are oviparous, and the eggs may be taken
through the drinking-water. They have been found in the biliary and
pancreatic ducts, as well as in various parts of the intestines. The ad-
ministration of thymol or male-fern is to be recommended.

Echinorhynchus moniliformis occurs in rats, and in one case, that of a
Sicilian, reported by Calandruccio, the ova were found in the feces.



Pentastoma Tenioides, — This parasite is an inhabitant of the nasal
fossae of the dog or horse, though it may also occur in man both in this
and in the larval form. The ova are ejected during sneezing, and are
then ingested by man. The larvae are found in the liver, lungs, and

Sarcoptes (Aca?-us Scahiei). — This insect produces the skin affection
known as "the itch," or scabies, an affection more common in Europe
than in America, where it constitutes only about 4 or 5 per cent, of all
cases of skin disease. It is most prevalent among the poor and the un-
clean. The female is visible to the naked eye, and is about 0.5 mm.
(•^ in.) in length ; the male is about 0.25 mm. (^ho ^^•)- I^oth are
nearly as broad as they are long.

The parasite penetrates the skin and lives in a burrow or cuniculus
that it makes for itself. The female lives in the end of the burrow, which
may contain a number of ova, and appears as a minute, brownish-black,
dotted, sinuous line, situated chiefly in the cutaneous folds, where the skin
is mostly delicate, as between the fingers. Secondary skin lesions, due to
scratching, are common. Sulphur ointment, well rubbed in after hot
bathing, is usually quite efficacious.

Sarcoptes scabiei hominis is a variety of the preceding that infests
other animals (cat, dog, cow, horse, wolf, goat, camel, etc.). Occasionally
it may gain an entrance into man's skin, but dies simultaneously in the
human host, although many invasions may occur.

Leptus Autumnalis {Harvest Bug). — The most common of several va-
rieties is a mite of a reddish color, having six legs armed with claws and
sharp mandibles. It arises among low bushes and thus appears about the
ankles and legs. It partially penetrates the skin, boring only far enough
with its short, thick head to procure nourishment. Artificial dermatitis
may be produced by the irritation of scratching. Mercury, sulphur, and
naphthol ointments suffice to destroy the parasite.

Demodex FoUiculorum {Comedo Mite). — This minute parasite may
be expressed from swollen sebaceous follicles of the nose, cheek, and
other parts of the face. It has a Avorm-like body with very short legs,
and is only about 0.2 to 0.4 mm. (gig- in.) in length. It is not known to
produce acne, as Avas formerly supposed.



Lice or pediculi live on and attack the skin. Three forms are found
on man : pedieulus capitis, pediculus corporis, and pediculus pubis.

The pediculus capitis is whitish or grayish in color, about 1 mm. (-^
in.) long (male), and has six legs under the front part of the body. The
oviparous female is nearly twice as long as the male, and lays from fifty
to eighty eggs on the hairs within a week. These ova, or "nits," ma-
ture in from three to eight days. Itching is the most prominent symp-


torn, and an eczematous eruption above and behind the ears and in the
neck is often associated. '• JPlica polonica " was a phrase once used to
designate the matted condition of the hair in extremely dirty, crusty,
and long-neglected cases of head-lice. Secondary adenopathy of the
cervical lymphatic glands is a common feature in neglected cases.

Pediculus Vestimentorum {Corporis). — This louse inhabits more often
the clothing than the body itself. It is larger than the head louse, and.
like the latter, moves slowly. The nits are found with difficulty on the
fibers of the underclothing. It sucks blood through a proboscis inserted
into the sweat pores, and after withdrawing leaves a minute hemorrhagic
speck. Irritation of the skin is produced, and in old cases, as in filthy
tramps, the skin becomes scaly and quite pigmented (vagabond's disease).
The efforts at scratching are almost frantic, and after a cure is effected
parallel white lines, the remains of scratch-marks, followed by atrophic
changes, may be visible, as in a case that I reported.^

Pediculus or Phthiriasis Pubis (Crab-louse). — This parasite is not limited
to the pubis, but attacks also the hairy region in the axilla, on the chest,
and may even reach the beard and eyebrows. It clings firmly to one or
two hairs close to the skin. Its six legs with strong claws are placed
closely together at the anterior part of the ovoid body.

Treatment. — The hair should be cut short Avhere the head-lice and
nits are abundant. Saturating the hair and scalp with kerosene oil for
twenty-four hours usually kills the parasites. Body-lice may be destroyed
by scalding the underclothing and hot-ironing carefully about the seams.
A hot soap-and-water bath is sufficient for the bod}"^, and sedative and
antiseptic ointments may be useful adjuvants. Mercurial and beta-
naphthol unguents usually suffice in treating for pediculus jJubis. Prof.
J. V. Shoemaker ^ affirms that naphthol is a remedy that seems to meet
the indications presented by the three forms of the disease ; he prepares
it as follows :

^. Beta-naphtol, 3J (4.0) ;

Cologne water, fgiv-vi (120.0-178.0).— M.

Cimex Lectularius or Bed-bug. — This too Avell-known parasite is flat,
brownish-red in color, and from 2 to 5 mm. (^^"3" ^^•) ii^ length. It in-
fests beds and public vehicles, emitting a disagreeable odor. It is a
blood-sucker, and causes considerable itching, local irritation, and urti-
caria even in some persons, while others are unmindful of their attacks.
Sulphur fumigation and mercuric chlorid applications to the harboring
places of the bed-bugs are effectual destructive agents. Saturated sodium
bicarbonate solution will relieve the burninor and itchinof.

Pulex Irritans [Common Flea). — This "ubiquitous" parasite is from
2 to 4 mm. (j^ "i i^-) i^ length, black or (when filled with blood) brown-
ish-red in color, having six legs, the hind ones of which are relatively
very large and powerful, enabling it to jump many times its own height.
A flea's bite causes a sharp sting, and leaves a slightly raised red spot
with a dark, pin-point center, the site of penetration of the biting appa-
ratus of the insect. Treatment is the same as for the preceding insect.

^ International Clinics, vol. iii., third series, p. 769.
* A Practical Treatise on Piseascs of the Skin, p. 849.


Pulex Penetrans Q^ Jigger"). — This parasite, also called "sand-flea,"
is indigenous to the West Indies, South America, and the Southern
States. The impregnated female penetrates the skin, and especially that
of the feet, for purposes of ovulation. As the distention with the eggs
occurs, swelling, pain, and even ulceration may appear. The sand-flea
is a small, egg-shaped insect, about half the size of an ordinary flea,
brownish in color, and exceedingly resistant to crushing force. Prophy-
laxis in regard to foot-wear is necessary. Essential and antiseptic oils
may also be put on the feet or stockings.

Ixodes [Wood-tick). — There are several varieties of tick- or wood-
louse that may attack the human skin, among which ixodes albipietus is
supposed to be the most common. Ixodes ricinus and ixodes hovis are
found on horses and cattle. They are blood-suckers, adhering to the
skin very firmly, and wheals may be produced by them. A drop of tur-
pentine, or of some such essential oil as anise or rosemary, will cause
them to loosen their hold.

Dermanyssus Avium et Gallinse. — These bird- and fowl-insects are
small and grayish-whiie in color, and may attack the human skin and cause
eczematous eruptions, owing to the scratching induced by the irritation.

Culicidae {Mosquitoes and Grnats). — The blood-sucking mosquito (eulex
auxifer), so well known, may also transfer to human beings the filaria
sanguinis hominis and the plasmodium malariae.

The g7iat (cuIex jnjnens) is very troublesome during certain seasons,
particularly along water-courses and in wooded districts. Its bite is
quick, sharp, and stinging.

The hirudo (leech) is a parasite that sometimes attaches itself to
bathers. In the tropics it has been known to cause severe bites and
inflammation. A remarkable case of hemoptysis is on record in which
a leech was found attached to the larynx, below the cords.

The bites and stings of bees, wasps, spiders, and ants have been
known to cause considerable inflammation, edema, and blood-poisoning.

Estridse {Bot-flies). — These may become parasitic in man in the larval
form. Species of the hydoxerma and dermatohia, that infest the skin
of the horse, ox, goat, etc., have also been observed among the Central
and South American Indians. They burrow beneath the skin of the
abdomen, scrotum, and other regions.

Muscidse {Common Flies). — Common flies afi"ect the skin of man by
depositing eggs in wounds. The ova hatch within twenty-four hours
sometimes, and the dipterous larvae may swarm to make the so-called
"living" wound or sore (mi/iasis vulnerum). The larvae or maggots do
not penetrate the tissues, however. The principal flies that infest wounds
are the flesh-fly {sarcopMla carnarid)., the blow-fly {ealliphora vomitoria),
the screw-worm fly {compsomyia macellaria), and the ordinary house-fly
{m,usca domestica).

Internal myiasis may also be caused by swallowing the ova of these
flies. The larvae may thus be vomited or defecated.

Epidemic urticaria is often caused by the migration of the caterpillar
(cnethocampa). Among other parasites that attack man and inhabit par-
ticular regions are the following : The simulium rep)tans, or creeping
gnat of Sweden ; the sey^oot-fly {zimbj of Abyssinia ; the ixodes carapato,
a virulent bed-bug in Brazil ; the hcematopota pluvialis (Clegg) of the
West Highlands.



Definition. — A clironic infectious disease communicable from per-
son to person by direct or indirect contact with a specific virus, or by
heredity. According to its clinical course, it is characterized by five
periods : (1) Period of primary incubation — the time which elapses be-
tween contact with the poison and the appearance of the chancre.
(2) Period of secondary incubation — the time which elapses between the
appearance of the initial lesion of the disease (the chancre) and the de-
velopment of its cutaneous manifestations. (3) Period of secondary
symptoms (skin eruptions). (4) Intermediary period characterized by
the absence of lesions, although evidences of existing dyscrasia can still
be found. (5) Period of tertiary symptoms. The hereditary form of the
disease is transmitted at the time of procreation by the sperm virile, by
the ovum, or by both. Prince MorroAv ' points out that the important
lesions of the disease are those that occur in the internal organs — visceral

General Patholog'y. — {a) Primary Lesion of Chancre. — This ap-
pears at the site of inoculation, and is characterized by infiltration of the
connective tissue chiefly with round cells, and also by larger epithelioid
and giant-cells. There is sclerosis of the small blood-vessels chiefly in-
volving the adventitia of the arterioles. The neighboring lymphatic
glands soon undergo hyperplasia and induration.

(/>) Secondary Lesions. — Macular and maculo-papular eruptions are
frequent, and, with the mucous patch, show round-cell infiltration of the
connective tissue and blood-vessels similar to that found in the chancre.
The favorite sites for mucous patches are the mucocutaneous junctions
(mouth, anus, etc.). Other lesions of this stage are general adenopathy,
alopecia, and pharyngitis.

(f) Tertiary Lesions. — These are circumscribed inflammatory prod-
ucts known as gummata. They appear in the connective tissue, bones,
periosteum (" nodes "), skin, muscles, brain, liver, lungs, kidneys, heart,
testes, etc. The gummata, though usually sharply circumscribed, may
take the form of diffuse infiltrations and vary in size — from a pin's point
to a hen's egg. Usually firm, they may be soft, and tend to form ulcers.
Their color is grayish, and on section they show a caseous semi-opaque
center, Avith a fibrous, translucent periphery.

3Iic)'oscopicaUi/, the gumma consists of small round cells forming a
true granuloma. The mass thus formed may either be absorbed or per-
sist ; but in most instances coagulation-necrosis, due to local anemia,
occurs in the center wuth conversion of the peripheral zone into fibrous
tissue. The central caseous material may be absorbed or appear as a
calcareous mass in the resulting cicatrix. Gummata of certain structures
(skin, mucous membrane, bones, and cartilages) often lead to destructive
ulceration and sloughing.

General Etiology.— Bacteriology. — Schaudinn and Hoffman- de-
scribed two spiral micro-organisms; one, from the deeper layers of the
chancre, condylomata, and lymph-glands, the specific organism, or the
spirochceta pallida ; while from the superficial part of the lesions the non-
specific spirochceta refringens. The spirocho'ta pallida in length varies

^ 3Ied. Neivs, March 23, 1901. ^ Deutsch. med. Wochenschr., May 4, 1905.


from one to six times the diameter of a red blood-cell, in width from
unmeasurable thinness to ^ //. MetchnikoiF and Roux ^ have demon-
strated this organism in acquired syphilis of man and in experimental
lues in the monkey and ape.

Predisposing Causes. — Since acquired syphilis originates only by in-
oculation, it is obvious that a break in the cutaneous or mucous surfaces
is essential to infection, such as a slight abrasion, fissure, or laceration,
etc., particularly of the genital mucosae. Other surfaces may also be
the seat of infection, as the lips, hands, etc.

Susceptibility to the virus is universal, and no age is exempt. He-
infection is exceedingly rare, but does occur.

Contagion of Syphilis. — The blood of a syphilitic during the second-
ary period, and the secretion from the chancre or any of the secondary
lesions, are contagious, the lesion at the point of inoculation always being
a chancre. The physiologic secretions, saliva, sweat, milk, and semen,
do not convey the virus, unless contaminated with the discharges fi'om
some of the lesions of the primary or secondary stage. The semen is
able to infect the embryo and, in turn, the mother. There is experi-
mental evidence to show that the gumma is infectious.

Modes of Infection. — (1) In a great proportion of the cases (about 70
per cent.) syphilis is transferred by illicit sexual intercourse.

(2) Accidental Inoculation. — This is not uncommon, (rt) Most fre-
quently it is accomplished through the pernicious custom of indiscrim-
inate kissing (lip-chancre), and I have personal knowledge of not less
than 8 instances in which infection has occurred through labial contact.
In Russia from 75 to 80 per cent, are acquired in this manner from pop-
ular customs.

ih) The site of inoculation may also be the mouth and tonsils, the
virus being conveyed during the low practices of sexual perverts or by
kissing. The wet-nurse may infect the mouths of suckling babes, or, vice
versa, the infant may infect the nipple of the nurse.

(c) The obstetric finger may become infected. Three instances of
the sort have come under my own observation, and Fournier gives the
details of 40 cases of primary syphilitic infection of the hand. In 30
of these the malady was acquired in medical practice (4 obstetricians,
20 general practitioners, 3 students, and 3 midwives). Montgomery ^
states that chancre of the finger is peculiarly frequent in physicians.

(d) Humanized vaccine virus may rarely transmit the disease.

(e) Accidental infection has, at times (though very rarely), taken place
in a variety of other ways — e. g., handling foul rags from the hospital
ward, by bed-clothing, clrinking-cups, the pipe and cigar, tattooing, etc.

Krafft-Ebing found that out of 3455 cases '^^^^ per cent, were of
extra-genital origin. The lesion was upon the lips in 51 per cent.

(3) Hereditary Transmission. — Paternal transmission (through the
semen) is much more common than is maternal, the period of greatest
danger being immediately after the father has become infected or dur-
ing the time of the secondai-y manifestations. The first-born, if the
father be syphilitic, is apt to show well-marked lesions. Appropriate
treatment of a syphilitic parent lessens the danger of transmission very

^ Bulletin de V Academic de Mededn, Paris, May 16, 1905.
2 Jour. Cutan. Diseases, April, 1905.


materially, however, and in such instances there is little tendency to
transmission shown after the third year. On the other hand, a syphi-
litic father or mother may beget healthy offspring, the infant having
acquired some immunity which protects it from its mother (Profeta's
law). Syphilitic children are also common to infected women. In the
majority of instances of hereditary transmission, however, both parents
are svphilitic, and under these circumstances the liability to infect the
offspring is much augmented. A woman who has become infected after
conception may bear a syphilitic child ; though the latter may, on the
other hand, escape infection.

Allusion may here be made to Colles's law — that a woman who bears
a syphilitic child enjoys, owing to a sort of protective vaccination with
the specific virus, perfect immunity, and this in the absence of all signs
of the affection. Coutts^ dissents from this opinion.

Clinical History of Acquired Syphilis. — ((/) Primary Stage. —
The typical initial lesion (chancre) appears about three weeks after in-
fection, and is followed soon by SAvelling and induration of the nearest
lymphatic glands. The primary sore begins as a red papule, Avhich
rapidly reaches its maximum, and then undergoes a central necrosis
with the formation of a sinall ulcer. The adjacent structures become
hard or cartilage-like — a characteristic to which the lesion owes its
name of *■' hard chancre." A small chancre may often escape detec-
tion, especially if it be situated inside the meatus. When situated upon
a mucous membrane it is always a erosion, which may be so
mild and of such brief existence as to come and go without the knowl-
edge of its bearer. Particularly is this the case in the female. The
general symptoms are negative in this stage.

(6) Secondary Stage. — This is announced about six weeks after the
appearance of the infecting chancre by moderate fever (100°— 101° F. —
37.7°-38.3° C), exceptionally higher, accompanied by languor, head-
ache, bone-pains, impaired digestion, and a slight degree of prostration.
There is angina, Avith hyperemia of the fauces and hard palate. The
blood shows a marked reduction in hemoglobin with some diminution in
the number of red cells. General lymphatic enlargeinent is seen, espe-
cially significant in the post-cervical and epitrochlear glands.

Skin eruptions are of many forms. The erythematous or roseolar is
the earliest and most common, coming out abundantly upon the trunk
(especially the chest), buttocks, thighs, and forehead. Another early
variety is the papular. The papules are small or large, hard, and
appear on the face, trunk, and flexor surfaces of the extremities.

3Iucous patches may appear on the visible mucous surfaces (angles of
mouth, tongue, tonsils, pharynx, vulva, vagina, penis, and around the
anus), and are among the early and constant lesions. The distribution
of these early syphilids is symmetric : their outlines are rounded ; their
color like that of a slice of raw ham (''coppery"); they are polymor-
phous ; and, as a rule, they excite neither pain nor itching.

Other and later-appearing eruptions may be pustular, and tuber-
cular. These show a tendency to bunch in certain areas, and hence
are less diffuse than the afore-mentioned eruptions ; and are not sym-
metrically distributed on the body.

' " Hunterian Lectures," Lancet, 1896, No. 3889.


Other frequent symptomatic conditions arise during this secondary
period, such as alopecia, hiryngitis. iritis, choroiditis, retinitis, and epi-
didymitis (more rarely). The hairs of the eyelids and eyebrows may fail
off and the finger-nails become brittle.

The secondan/ symptoms last from two to three months (the usual

Online LibraryJames M. (James Meschter) AndersA text-book of the practice of medicine → online text (page 52 of 178)