stools during the 24 hours) alternating with constipation, anæmia, headache, vertigo, disturbance of vision, epilepsy and melancholia. Many cases have lately been reported of high temperature and convulsions directly due to the presence of the ascaris lumbricoides in the intestine.

A boy æt. 8, presented the features of basal meningitis. The temperature was 102-103°F., pulse 160, respiration 60. There was spasm of the right arm and hand, the limb being constantly drawn to the right iliac fossa as if to remove some irritant. At the necropsy six ascarides were found in the colon, one in the ileum and one in the vermiform appendix. A girl, æt. 12, had a rigor followed by intense headache, thirst and a temperature of 104-3°F. Tonic and clonic spasm of the arms developed into a typical epileptiform attack. After the expulsion of an ascaris the symptoms disappeared immediately.

The nematodes present in the Birmingham outbreak are found in connection with intense itching on the shoulders, chest, dorsal surface of the fingers and flexor aspects of the limbs, followed by the appearance of grey, ashy white vesicles containing a clear fluid. There is no distinct red zone around, the vesicles remain. discrete, dry up and form crusts which fall off after a few days leaving a small scar. The " craw-craw of Western Africa presents a similar condition and is exceedingly prevalent amongst young males and those who wade in shallow streams.

The distomum spathulatum causes increased appetite, hepatic enlargement, oedema of the legs and night blindness. At a later stage, diarrhoea, ascites, anæmia, hæmorrhages from the nose and intestine are all frequent. The course is exceedingly chronic, the patient improving in health during the winter and becoming worse during the summer. The cercariæ are supposed to invade the liver tissues in the spring or early summer.

Circulatory System. A case of severe anæmia occurred through the presence of tænia solium in the alimentary canal, the red corpuscles dropping to 1,000,000 per cmm. Bothriocephalus latus caused death in a woman æt. 30, who lived in a fish-eating district. She had suffered from worms for several years. On examination of the blood the hæmoglobin was lowered to 20 per cent., and megaloblasts and normoblasts were present in large numbers. Temperature 39°C. (102.2 F.). Under appropriate

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treatment six worms were expelled, but death ensued five days later from the progressive anæmia. At the autopsy the usual signs of anæmia were found. The necessity for routine examinations of the blood received unexpected confirmation in the case of a soldier who was discharged from the Army suffering from leukæmia. A low percentage of hæmoglobin was found to be associated with a marked rise in the numbers of the eosinophile leucocytes. The administration of anthelmintics led to the ejection of ankylostoma duodenale and their ova. Considerable attention has been lately given to the blood conditions in parasitic diseases and the average results of numerous papers may be presented in tabular form.

It thus appears that in affections due to the presence of the higher animal parasites, eosinophilia is a constant feature. Whether this is due to the actual production of eosinophilous forms or to the transformation of neutrophile polymorphonuclear leucocytes is not yet determined. The systematic examination of the blood should yield reliable evidence of the existence of these parasites in the body, and also indicate their complete or incomplete expulsion. Such knowledge would prove extremely useful in the case of the ankylostoma and the filaria medinensis (guinea worm). A practical application of this has been already made. In the fæces obtained from one of the closets in a large college the eggs of the ankylostomum duodenale were found. The pupils who had used the receptacle on the specified day were asked to submit themselves to examination, but their fæces yielded negative results. An examination of the blood of each pupil was made, eosinophilia was observed in two cases, and ova subse

quently detected in their fæces. In ankylostomiasis the leucocytic reaction is greatest just after infection, and later tends to disappear, although the worm is still in the intestine. The hæmoglobin percentage follows the same course. At first it is reduced down to 20 to 40 per cent. and gradually returns to about 80 per cent., although in a few scattered cases it remains persistently low. Hydatid disease of the heart has been observed.

Alimentary system. Rupture of the hydatids into the peritoneum and their occurrence in the appendix and spleen have all been reported. A boy, æt. 19, had infective endocarditis with the usual pyæmic results and also an aneurism of the peroneal artery. Both arose from the occurrence of suppuration in an hydatid cyst which had previously given no clinical signs. Appendicitis may arise from the mechanical irritation of intestinal parasites or through actual perforation and subsequent peritonitis. Trichocephalus dispar causes appendicitis by injuring the mucosa during the removal of the blood.

Perforation of the appendix occurred in the case of a boy, æt. 16, and proved fatal five days later after the usual symptoms of high temperature and rapid pulse. At the autopsy an ascaris lumbricoides was found in the abdominal cavity and a second was half way through the perforated appendix. Oxyuris vermicularis only causes appendicitis in its role as a foreign body, but there is always the possibility of secondary infection.

A girl, æt. 9, had rigors, vomiting and excessive abdominal pain chiefly localised around the umbilicus. Pulse 124, temperature normal. Dulness was observed in the right flank. Five days later laparotomy was performed. The appendix was red, swollen, gangrenous and perforated at one point. It contained two "pin worms" and staphylococci pyogenes.

The oxyuris vermicularis has been also lately observed in abscesses in Douglas's pouch and in perirectal abscesses.

Respiratory system. A case of spontaneous recovery from hydatid disease of the lung is recorded.

A patient presented the physical signs of a tuberculous focus in the upper lobe of the right lung, the temperature was irregular in character and there was some tuberculosis in the ankle joint.

Hæmoptysis was frequent, but one day shreds of membrane were expectorated. These on examination proved to be laminated. Other portions followed, the physical signs gradually disappeared and a smooth cavity remained which was filled with air and which gave signs of gradual contraction.

Genito-urinary system. In bilharzia disease the urine contains. large numbers of leucocytes, of which 70 per cent. are eosinophiles. The number of ova and the amount of blood excreted both vary considerably. Transitional epithelium has been repeatedly observed. Sexual impotence appears to be a very frequent sequela and 85 per cent. of the vesical calculi occurring in Egypt result from the presence of the distomata in the bladder. Echinococcus. cysts have been met with in the kidney.

Nervous system. Hydatid cysts of the spinal cord causing severe compression myelitis have been observed and in the cerebrum several cases of cysticercus and one of hydatids have occurred.

A woman, æt. 51, became comatose just before an operation for the removal of a large cyst, and after the operation was concluded epileptic attacks developed and were followed by loss of speech. She died five days later. At the autopsy ten cysts, varying in size from a hazel nut to a small pea, were found in the neighbourhood of the left Sylvian fissure. The ventricles, especially the left, were dilated and contained an abnormally large amount of fluid.

A man, æt. 47, with a several years' history of headache, vertigo, ptosis, exophthalmos, aphasia, presented on admission to the hospital, ataxia, loss of orientation, slight agraphia, and "choked" optic disc. An epileptic fit was followed by temporary blindness, hemiparesis, aphasia, slight optic neuritis and rapid death. The necropsy revealed a collection of small cysts in the subarachnoid space, especially marked at the base and along the large vessels, around the optic chiasma and cerebellum, and between the posterior roots of the cord. Meningitis probably developed when the parasite died. In addition to the cysts, vascular changes, ependymitis and hydrocephalus were present.

In children chorea has been noted in association with the presence of tænia solium or mediocanellata in the intestine. The attacks commence a few weeks after the passage of mature seg

ments and cease when the worm is dislodged. Endocarditis and pericarditis sometimes ensue.

Special organs. Eye lesions often accompany the well-known general symptoms of ankylostomiasis. They consist of changes in the intra-ocular pressure, excessive pulsation in the arteries and veins and hæmorrhages into the fundus. Microscopically, the vascular endothelium shows fatty degeneration and the bloodvessels exhibit sclerotic changes. As a rule, the visual field is contracted, and diplopia, amblyopia and amaurosis may be met with. Cysticercus has been observed in the subcutaneous tissues and hydatid cysts have been noted in the ribs and in the muscles of the thigh. In the latter case spontaneous expulsion occurred.

THERAPEUTICS. As a rule, the well-known anthelmintics are quite sufficient to expel the ordinary worm. Any apparent newness in the prescriptions is due to our old friends dressed in the latest Parisian or Viennese style. Tænia nana has been successfully treated by the administration of olei resini aspidii 3j, extr. kamalæ hd. 3j, ext. krameriæ 3ss at 9 a.m. followed by olei ricini 3j in an hour or so. Tænia cucumerina succumbed rapidly to the com

bination of one drachm of kamala with a small dose of calomel. As regards oxyuris vermicularis, it may be pointed out that the young parasites must be dislodged from the small intestine as well as the adults from the colon. For the former, calomel is exceedingly effective, for the latter, the patient should be placed in the knee-elbow position and three litres of 0.2 to 0.5 per cent. solution of medicated soap be injected per rectum. The application should be repeated twice at intervals of a week or so.

Ankylostomiasis is usually treated by giving five grains of calomel at night, followed the next morning by two or three drachms of ext. filix mas on an empty stomach; the calomel is repeated the next morning, another dose of male fern the following morning and still another five grains of calomel on the third evening. The fæces are examined for six days and if ova are not found the patient is considered to be cured; if ova are found then the drugs are repeated in toto. Thymol is also useful in 20 grain doses, but it sometimes produces discomfort. A mixture composed of filix mas, thymol, chloroform and castor oil has apparently a widespread reputation. To avoid stomatitis, purgatin" has been used and is said to be as effective as calomel.