TRICHINOSIS-REPORT OF TWO CASES*

IN reporting the following cases of trichinosis it is not my intention to enter into an exhaustive discussion of the disease, nor do I claim to add anything to what is already known and to be found in the literature on the subject. But as cases of this disease are far from uncommon in this part of the country, and as opinions in regard to the treatment of the disease differ widely, I publish the following two cases to enunciate my views on the subject:

CASE I.-On November 27, 1880, H. C. Hansen, thirty-seven years of age, a plasterer and contractor living at 635 North Ashland Avenue, bought a smoked and sugar-cured ham, weighing 9 pounds, of a butcher on Milwaukee Avenue. On the next day, November 28th, at 6 o'clock in the evening, the whole family partook freely of the ham, which was sliced and eaten raw. Hansen ate from 2 to 4 ounces, or, as he expressed it, in all about as much as twice the size of his thumb. The next day, November, 29th, he ate some more of the ham. November 30th he went out to work as usual, but about 3 o'clock in the afternoon complained of severe pain in the stomach, together with diarrhea. To relieve this he took two drinks of bitters,-whisky and horehound,-which he says eased the pain, and he went to work again. December 1st the pain and diarrhea recurred more severely. December 2d the diarrhea became so painful that he was confined to his bed, the bowels moving about every ten or twenty minutes. December 4th I was sent for. On questioning Hansen and his wife in regard to what they had eaten they answered, as usual, that they had eaten nothing but ordinary food, the same that the children had had, and that they had not eaten raw meat. On December 6th, however, when asked directly if they had not eaten smoked ham, they acknowledged that they had. By this time they had eaten, boiled and raw, about 6 pounds of the ham. They asserted that the boiled meat was well done, and that they had eaten very little raw. I immediately took specimens from different parts of the ham, and, on microscopic examination, found it to contain numerous encapsulated muscle trichinæ, averaging about 30 to each grain of the meat.

The patient's temperature remained about the same-101° to 102° F.—until December 12th, when the whole family were removed to the house of a relative in order to obtain better nourishment and attendance.

December 13th, 9 A. M.: The temperature has not exceeded 102° F. at any time in the last twenty-four hours. The patient has diarrhea, movements of the bowels occurring every thirty to sixty minutes, and has considerable pain in the left arm. He drinks port wine, beer, cognac, etc. Between 8 P. M. and 3 A. M. he ate an omelet, soft-boiled eggs, veal steak, and drank three bottles of beer and a considerable quantity of milk. He can at no time sleep more than a few minutes, and his sleep is uneasy. 12 NOON: Pulse, 90; temperature, normal; he suffers excruciating pain in the muscles of the arms and legs. 1 P. M.: Pulse, 88; temperature, 100° F.; has a good appetite, but considerable muscular pain. 3 P. M.: Pulse, 84; temperature, 100.5° F. 6 P. M.: Pulse, 90; temperature, 102.5° F.; he has vomited considerably and has no appetite. 7.30 P. M.: The patient is almost prostrated from the nervous shock and terrible muscular pain. 9.30 P. M.: Pulse, 90; temperature, 101.5° F.; he has eaten soup with rice with good appetite. 10.30 P. M.: * Chicago Med. Review, 1881, vol. iii, p. 208.

Pulse, 80; temperature, 101.2° F.; prescribed morphin syrup; he seems in good condition, but still feels pain.

December 14th, 1.30 A. M.: Pulse, 70; the patient could not endure the pain, so a hypodermic injection of morphin was given him. 9 A. M.: Temperature, 99° F. 12 NOON: Pulse, 70; temperature, 100.5° F.; he is resting easily and sleeps. 3 P. M.: Pulse, 90; temperature, 101.5° F.; he is suffering intense pain. 5 P. M.: Pulse, 78; temperature, 103° F.; complains of pain in the side. 6 P. M.: Pulse, 90; temperature, 103.5° F.; ate a plate of soup and drank a glass of beer. 8 P. M.: Pulse, 80; temperature, 103.5° F. 11 P. M.: Pulse, 88; temperature, 103.2° F. 12 MIDNIGHT: pulse, 80; temperature, 102.5° F.; sleeps and has little pain.

December 15th, 8 A. M.: Pulse, 78; temperature, 100° F.; slept fairly well since midnight. 2 P. M.: Pulse, 86; temperature, 101.5° F. 4.45 P. M.: Pulse, 94; temperature, 102.5° F.; feels easy when he does not move. 7 P. M.: Pulse, 94; temperature, 102.3° F.; suffers excruciating pain all over the body. 10 P. M.: Pulse, 90; temperature, 104.2° F.; the pain still continues.

December 16th, 9.30 A. M.: Pulse, 88; temperature, 100° F.; the patient has rested easily since 2 o'clock this morning. Until 2 o'clock he had a passage every half-hour. Since 7 A. M. he has had only two passages. There is pain on pressure all over the muscles of the arms and legs. He suffers no pain when he remains absolutely immobile in bed, but the slightest active movement causes pain in the muscles thus brought into action. He has had four or five glasses of beer this morning. The pulse is soft and weak. 2.45 P. M.: Pulse, 90; temperature, 101.5° F.; feels weak, but is otherwise comfortable. 5 P. M.: Pulse, 90; temperature, 101.5° F. 7 P. M.: he vomited and felt weak afterward. 9.15 P. M.: Pulse, 100; temperature, 102.5° F. 11 P. M.: Pulse, 84; temperature, 102.2° F.; the patient feels well.

December 17th, 9 A. M.: Pulse, 84; temperature, 99.7° F. 5.15 P. M.: Pulse, 84; temperature, 100° F. 10 P. M.: Pulse, 84; temperature, 101° F.

December 18th, 9 a. M.: Pulse, 74, full and strong; temperature, 99.5° F. 10 P. M.: Pulse, 80; temperature, 101° F.; all going well.

December 19th, 10.30 A. M.: Pulse, 70. 11 P. M.: Pulse, 88; temperature, 100° F. December 20th, 9 P. M.: Pulse, 86; temperature, 99.5° F.

December 21st, 8.30 A. M.: Pulse, 76; temperature, 99° F. 9 P. M.: Pulse, 106; temperature, 100° F.

December 22d, 9 A. M.: Pulse, 90; temperature, 99.5° F. 9 P. M.: Pulse, 96; temperature, 100.5° F.; the patient suffers some pain on pressure over the epigastrium; feels generally weak; there are stiffness and weakness in the extremities and pain upon motion. December 24th, 10 P. M.: Pulse, 100, weak; considerable edema around both anklejoints, and extending almost to the knees; no pain when the patient remains immobile. December 25th, 10 P. M.: Pulse, 104.

December 30th: The patient's left leg is cold, and he cannot get it warm, even by the stove.

December 31st: Temperature normal; from 10 o'clock last night until morning he experienced a very unusual degree of heat in both legs, so that he could not bear to have them covered at all. He actually suffered from heat, but experienced no itching sensation.

From this time on the patient's pulse and temperature remained normal. The diarrhea lessened gradually, and ceased in about two weeks. About the middle of January, 1881, he was able to sit up.

January 15th: Appetite good; sleeps well; pulse and temperature normal; no diarrhea; looks pale and emaciated; the patient gets tired after walking a few steps; has edema of the legs in the evening, which disappears in the morning; there is no pain on pressure of the muscles.

With a harpoon I took out of the right gastrocnemius muscle about a cubic millimeter of muscular tissue. On microscopic examination this was found to contain three

living muscle trichinæ, one of which was rolled up in a spiral and apparently about to become encapsulated. The two others were free. Whether the two latter were torn out of newly formed capsules or were not yet encapsulated I was unable to determine. For the next two months the patient was very weak and pale. Muscular strength returned very slowly, so that it was not until March, more than three months after the inception of the disease, that he was able to walk about the whole day and think of recommencing work, and even now, about five months after the infection with trichinæ, he has not entirely regained his strength.

CASE II.-Mathilde Hansen, wife of the last patient, thirty-six years of age, was attacked by the same symptoms, in a more aggravated form, four days after her husband began to feel the effects of the infection. She partook of the ham at the same time, and says that in all she ate three thin slices of the raw, and possibly two pounds of the boiled, meat, selecting the meat nearest the bone.

December 12th, 2 P. M.: Pulse, 130; temperature, 106° F. 5 P. M.: Pulse, 130; temperature, 105° F.; has no pain and is cheerful; ordered 5 grains quinin every four hours. 6 P. M.: Pulse, 126; temperature, 103.5° F.; complains of pain behind the sternum; cannot get breath, and hands and feet are cold. 8 P. M.: Pulse, 120; temperature, 104.2° F.; has the desire to vomit but cannot; suffers intense pain. 9.45 P. M.: Pulse, 116; temperature, 103.5° F.; much pain and vomiting. 11 P. M.: Pulse, 112; temperature, 102.5° F.; intense pain.

December 13th, 1 A. M.: Pulse, 102; temperature, 104.5° F.; vomiting and pain. 2.30 A. M.: Pulse, 100; temperature, 103.5° F.; hypodermic injection of morphin was given, after which the patient felt more comfortable and slept a little. 6.30 A. M.: Pulse, 100; temperature, 103° F.; feels more easy; ordered digitalis and laudanum and the application of an ice-bag to the pit of the stomach. 8.30 A. M.: Pulse, 100; temperature, 102° F., administered wine and cognac. 9.30 A. M.: Pulse, 98; temperature, 101° F.; vomiting; ` the wine and cognac continued. 11.30 A. M.: Pulse, 96; temperature, 101° F.; feels easy, but vomits; continued wine and cognac. 1 P. M.: Pulse, 90; temperature, 99° F.; appetite is returning slowly; Liebig's extract of meat was given. 3 P. M.: Pulse, 96; temperature, 100.5° F.; considerable vomiting. 6 P. M.: Pulse, 90; temperature, 101.2° F.; vomiting and pain. 9 P. M.: Pulse, 90; temperature, 100.5° F.; pain in the stomach; morphin syrup was ordered. 10 P. M.: Pulse, 90; temperature, 100.5° F.; the pain continued and the morphin was again administered.

December 14th, 1.25 A. M.: Pulse, 80; temperature, 100.2° F.; cannot sleep, but seems to have less pain. 6 A. M.: Pulse, 80; temperature, 100.4° F. 8.30 A. M.: Pulse, 90; temperature, 99.9° F.; has slept a little. 12 NOON: Pulse, 94; temperature, 99.9° F.; sleeps and rests easily. 5 P. M.: Pulse, 84; temperature, 100° F.; feels comfortable; has eaten boiled flounder with apparent relish. 9.30 P. M.: Pulse, 96; temperature, 100.2° F.; complains of pain.

December 15th, A. M.: Pulse, 84; temperature, 97.5° F.; very weak and does not sleep. 9 A. M.: Pulse, 84; temperature, 98.2° F.; says she "can't feel" her legs. 2 P. M.: Pulse, 98; temperature, 99° F.; there is constant formication in all the muscles. 4.30 P. M.: Pulse, 100; temperature, 98° F.; formication with a great deal of heat over the whole body. 7 P. M.: Pulse, 90; temperature, 99.5° F. 10 P. M.: Pulse, 94; temperature normal.

December 16th, 7 A. M.: Pulse, 98; temperature, 99.5° F.; has drunk a bottle of champagne since 10 o'clock last night and has slept a little. During the night she had passages from the bowels with tenesmus five or six times every hour. 12 NOON: Pulse, 100, and very weak. The patient has had three or four passages since 7 o'clock this morning, at which time she had slight formication around the extremities, especially in the legs, which felt stiff. She has no pain, but appears very weak and debilitated. She is extremely nervous, and cannot endure the least noise. Her sleep is interrupted, and

she can doze off for only half an hour at a time. She has had coffee, fish, and beef-tea. 2.30 P. M.: Pulse, 96; very weak; temperature, 98.2° F.; the extremities are cold; laudanum and wine were ordered. 5 P. M.: Pulse, 100; temperature, 100° F. 6.15 P. M.: Pulse, 120; temperature, 99.9° F.; has had three movements of the bowels since 5 o'clock. 11 P. M.: Pulse, 94; temperature, 100° F.; sleepy and feels comfortable.

December 17th, 9 A. M.: Pulse, 92; temperature, 97.5° F.; her voice is very weak and she feels weaker than yesterday. She was able, however, to walk out to the closet five or six times during the night. 5.30 P. M.: Pulse, 108; temperature, 100° F. 10 P. M.: Pulse, 112; temperature, 102° F.

December 18th, 9 A. M.: Pulse, 96, very weak and soft; temperature, 98° F.; she had five movements of the bowels during the night. 4.30 P. M.: Pulse, 104; temperature, 98° F.; excessive vomiting and diarrhea, but eats well. 10 P. M.: Pulse, 106; temperature,

98.2° F.; patient comfortable.

December 19th, 8 A. M.: Pulse, 96; slept from midnight until 6 o'clock this morning. 11 P. M.: Pulse, 102; temperature, 99.5° F.

December 20th, 9 A. M.: Pulse, 102; temperature, 99.2° F.

December 21st, 8.30 A. M.: Pulse, 108; temperature, 98.5° F.; ordered tincture of digitalis, 10 drops. 9 P. M.: Pulse, 106; temperature, 100° F.

December 22d, 9 A. M.: Pulse, 108; temperature, 98.5° F. 9 P. M.: Pulse, 100; temperature, 99.7° F.; no pain; difficult respiration; weak; has slight cough; heart-sounds normal; no râles to be heard in the lungs. There is stiffness, but not pain, on moving the lower extremities. Has had three to five half liquid stools.

December 24th, 10 P. M.: Pulse, 108, weak and soft; complains of pain in the breast; no movement of the bowels since 5 o'clock this morning. December 25th: Pulse soft and very weak. only for a few minutes at a time. 10 P. M.: Four liquid stools in the past twenty-four hours.

The patient is very weak and can stand
Pulse, 102, weak; temperature normal.

After this time there was no further rise in temperature. The stools were still liquid until about the middle of January, 1881. The patient gradually became stronger, and was able to be up and about the house about the end of January. Had no edema of the legs at any time. About the middle of February she was able to do her own housework, but became easily fatigued. She has now (April) regained her former state of health.

A remarkable feature in this case was the high temperature in the second week after the infection (as indicated by the accompanying chart, Fig. 29), which was so uncommon as to make me believe that some complication had set in, but failing to find any after careful examination of all the organs, I could not attribute it to any other cause than the trichinosis, and thought that I had a very severe case to deal with, which I expected would terminate fatally from collapse during the continuance of the extremely high temperature. After twenty-four hours, however, the temperature went down and did not rise again, and, contrary to my expectations, the patient recovered.

Three children of the above patients, girls, aged respectively fifteen, five, and two years, partook of the ham in question, both raw and after boiling, in quantities that cannot be ascertained, but no symptoms of the disease appeared in them at any time.

TREATMENT

The first question which presents itself in incipient cases of trichinosis is naturally whether it is possible, and if so in what way we may hope, to remove from the intestinal canal the full-grown and gravid female intestinal trichinæ and the newly born embryo muscle trichinæ,

before they perforate the wall of the intestines and get out into the tissues.

If we were so fortunate as to know within a few hours after a meal of trichinous meat had been eaten that such had been eaten, we should, of course, administer emetics and strong purgatives, but this resource is practically out of the question, as the patients do not begin to have any distressing symptoms until a day or two after eating the diseased meat, and then, in most cases, several days will elapse before medical aid is sought, and it will probably take a day or two more for the physician to make up his mind as to the diagnosis.

If the diagnosis can be made in the first week of the disease, in cases

P. M.

12. P. M. 13. A. M P. M. 14. A. M. 15. A. M. P. M. 2 4 6 8 10 12 2 4 6 8 10 12 2 4 6 8 10 12 2 4 6 8 10 12 2 4 6 8 10 12 2 4 6 8 10 12 2 4 6 8 10 TEMPERATURE

in which there has been no diarrhea, we should not hesitate to give laxatives and keep up frequent and liquid stools for some time. But in most of the cases the first stage of the disease is, as it was in the above-mentioned cases, characterized by a violent diarrhea, caused by the emigration of the embryo muscle trichinæ through the intestinal walls.

When, therefore, as in these cases, liquid stools are as frequent as from 10 to 20 in the twenty-four hours, it seems to me that purgatives are not only unnecessary, but are even contraindicated, for the following reasons: We know that we have to do with a disease which will last for a long time and greatly debilitate the patient. To obviate this inevitable debilitation, the only remedy in our power is a nourishing and roborating treatment. Purgatives would tend only to diminish or do away with