no doubt harmless, and the patient died of Cirrhosis of the liver. " Vircliow found the parasite in Wurzburg and Berlin, Wagner in Leipzig, Frericlis in Breslau, five times in 47 autopsies. Zenker first called attention to the occurrence of the larvte in man, having found it nine times in the liver in 168 autopsies. According to Zaeslin two cases occurred in Basel in 1,914 autopsies. At Kronstadt, larvae were found six times in 659 autop- sies, most frequently one or two specimens being found in the liver. Friedberger and Frohner state that the parasite is found more commonly in some districts than the others. They found it frequently in Berlin, but only exceptionally in Munich. Hering found it once only in Stuttgart, while Colin found it in 64 out of 630 Parisian dogs examined. The parasite seems to be present only in the larger breed of dogs, such as mastiff' and in the butcher's dogs, and was found oftenest in the ethmoidal cells firmly attached to the mucosa." The adult of L. serrata is more rarely found than the larval forms, but are most frequently found in the nasal and air passages of dogs and wolves. An account of these parasites is given in Castellani and Chalmers' new edition, page G21. Dr. K. C. Connor described a case of tetanus with a six-day incubation period ; he recovered and was treated with antitetanic serum. Lt.-Col. John L. Phillips, U. S. Army, Assistant Chief Sanitary Officer, and Dr. D. E. Keeder, describe diphtheria cases in the Canal Zone, where this disease is endemic, though it is sugges- ted that it is spread by visitors returning from the United States. Dr. Deeks and Dr. Connor describe cases of Pellagra and the former believes pellagra to be " due to a not Carbohydrate" auto-intoxication, alone due to but to all foods." sugar, " starchy Dr. Connor writes of atypical forms of plague." Dr. Clark and Dr. Darling have a valuable article on Status Lympbaticus. Dr. Henry Weinstein describes cases of Ainhum occurring in one family, in an African with a European name and in his family. The article gives a good account of the disease, and the cases reported are well illustrated. We quote the following remarks on this tropical disease, which has been very little written about since the late Dr. A. Crombie discussed its causation in these III. columns many years ago. CANAL ZONE MEDICAL ASSOCIATION.* F. C. Wellman reports a case of ainhum and summarizes the various theories advanced hitherto : October 1911 to March 1912. 1. Due to injury, foreign - (Vol. TV, Pt. 2.) bodies, etc. ... (Manson, Eyles). 2. Self-mutilation, instru- of the Canal Zone ments, etc. As usual the Congenital spontaneous proceedingsfull Medical Association are of interesting amputation (Proust.) 4. A form of mutilating matter. leprosy ... (Zambaco Pasha.) and Clark describe an unusual type 5. A form of troplio neurosis (Wucherer, Schenbe, Darling.) Drs. Darlino 6. A c a 1 iz e d Adami "Chronic forn of 1 o of called hy Scleroderma ??? (DaSilva tuberculosis, " Lima.) m a Jamaican Negro, hyperplastic tuberculosis In addition to the above, Wellman suggests that the 2^ Tho ?ime writers describe two cases ao-ed chigger (Sareopsylla penetrans) may be a causative factor Serrata in a native of infection by Lingua.ata in some of the cases. larva was hut It is reasonable for of discussion to of Central America. The parasitic, quite purposes combine 1 and 2 as belonging to the same category, J. C. C. Prass, Mount Hope, Canal Zone, Panama, namely, external influences. The cause of ainhum has 328 THE INDIAN MEDICAL GAZETTE. [Aug., 1913.

been ascribed to injury by foreign bodies coming in The common entamoeba are E. histolytica, E. tetragena, contact with the most dependent part of the foot, the and E. coli* little toe. It is claimed that barefootedness of the class The parasitic forms are subdivided further into the but of people affected is a very important factor. Many parasitic nonpathogenic, E. coli, and into the authors, who have reported cases in the literature, have pathogenic E. histolytica and E. tetragena. While E. coli ruled out absolutely external injury. If barefootedness is not regarded as an organism that invades tissues, not a were a cause, the natives of many countries should be it is unlikely that if breaV in the mucosa or bowel affected, whereas most of the cases reported were in wall-should occur, E. coli might vegetate in the peri- negroes living in cities and wearing shoes. Da Silva toneal exudate for instance. Recently while taking Lima has not seen the disease in the barefooted temperatures by rectum of a monkey that had been inoculated from a case one Brazilians or among the Creoles. Why should the of measles, of the thermo- disease attack males almost exclusively and shun the meters was broken and penetrated the peritoneum barefooted women ? How is the hereditary factor to be through the rectum. Peritonitis ensued and at autopsy ruled out ? Although the natives of Africa, India, six days later, a yellow typical entamoebic inflammatorj- was seen over the Polynesia, and other parts of the globe inflict upon process extending peritoneal surface of the in the and about the caecum themselves many injuries by wearing ornaments upon large bowel, pelvis, exposed parts of the body such as nose, lips, toes, etc., Tn the exudate, were many entamoebas. yet ainhum could hardly be ascribed as due to them, The specific identification of entamoebae is of the 3. Proust contends that ainhum may be due to con- greatest importance to physicians and sanitarians. To genital malformations. He claims that as a result of the former, for the reason that some of them believe that some interference in the development of the foetus the pathogenic type recognized as E histolytica'^ some parts may become arrested, causing amputation able to specific medicaments, while the type recognized as of fingers and toes, and that the umbilical cord or E. tetragena is not so amenable to specific treatment To for the of fibrous projections may ensnare these parts causing the surgeon, identification pathogenic enta- arrested development, leading later on to spontaneous moeba1 in certain cases may determine his opinion as amputation. to the advisability of an exploratory operation for Zambaco Pasha is the most enthusiastic supporter, of entamoebic liver abscess, or performing a caecostomy. the theory that ainhum is a form of mutilating anesthetic The subject is of importance to sanitarians on account leprosy. He studied his cases in Syria and especially at of its relation to 'carriers,' and to the sanitary measures mode of Beirut where leprosy is very common. Many diseases directed specifically against the transmission."... " of obscure nervous origin such as syringomyelia, The cultivable species of the genus amoeba? are not morphea, scleroderma diffusum and ainhum are attributed parasitic in the intestinal tract of man When obtained by him to leprous manifestations. Dr. Collas who in cultures from the intestine, they probably are derived observed ainhum among Hindus is quoted as holding from cysts of amoebae that have been ingested with views similar to those of Zambaco Pasha water or food and have passed unchanged through the It is to be noted that all of his cases were Caucasians intestinal tract. of all ages and both sexes The lesions are described as The entamoeba? parasitic in the intestinal tract of occurring alike in hands and feet, fingers and toes, with man belong to a distinct genus. They are strictly irregular distribution. The clinical symptoms are those obligatory parasites and are incapable of multiplication of anesthetic leprosy with all the nervous symptoms? outside of the body of their host They cannot be anesthesia, analgesia, electrical and thermal disturbances, cultivated on Musgrave and Clegg's medium." together with muscular atrophy. There were also "Influenced by the cultural work of Musgrave, observed perforating ulcer, atrophy of the nails, and Clegg, and Walker, the doctrine of symbiosis as enun- pigmentation of the skin. Zambaco Pasha also has ciated by Musgrave was considered essential to an leanings toward the hereditary tendencies of leprosy understanding of the bionomics of entamreba?. This and considers the pathological findings in spontaneous doctrine usually has a stricter application than that, mutilating leprosy and ainhum as similar. made by Musgrave in his paper on bacterial symbiosis, De Brun takes issue with Zambaco Pasha. He, too, published in the Journal of Science, 1909, in Philippine' observed his cases at Beirut. In more than 900 cases which he stated that Symbiosis may be defined as observed by him not one was seen in which the fifth toe representing all phases of association between living was exclusively affected. Although he found a constrict- organisms. Beginning with commensalism on the one ing band in some of the fingers and toes it was rather hand, and including true parasitism on the other, in irregular, not circular as in ainhum. which either component is influenced in nutrition, Ainhum rarely begins before the period of adolescence ; metabolism, production, or in some other manner by occur ? ? ? ? ? ? anesthetic mutilating leprosy may at any age. the presence of the other.' . The racial factor is distinct in ainhum but not in leprosy. "In the work of the ' culturalists' it was found Although very seldom toes other than the fifth may be necessary to seed the nutritive plates with bacteria for involved ainhum by the often symmetrical process ; in the amoebae to live upon. In other words, the amoeba3 leprosy, fingers, toes, and other parts are affected. could not find ready-made or in any shape, nutritive (Polymorphism) Ulcers, fissures, suppuration, and other substances in the media which on the other hand were inflammatory conditions are seldom noticed in ainhum, amply nutritive for bacteria. Recent researches have but are very common in mutilating anesthetic leprosy. indicated very positively that the amcebw studied so faithfully by Musgrave and Clegg were not parasitic Dr. S. T. has a valuable article on Darling very entamoebabut were free-lioina specimens of amoebce. amoebsB and entamoebse (we are glad to see It is possible, and indeed highly probable, that cultivation the Canal Zone does not patronise the usual inferences made from a study of experiments " " with whose normal habitat is the American and he out the need free-living amoebae, spelling) points sunlit soil or stagnant water and whose only source of of using an expert to tell the difference between food is air, soil, and water bacteria, cannot be applied entamoeba and the free living forms:? by way of analogy to an obligate parasite such as a entamoeba." "There are several kinds of amoebre which trouble the pathogenic doctor in the are divided into * tropics, and they groups, Note.?Recent statements by Hartmann and DoHein on in depending whether they are parasitic the intestinal would seem to indicate a growing belief in the minds of tract or not. Those developing in the bowel are called protozoologists who have worked in this field, tint Schandinn's of what he called entamnebte, while those that merely pass through in an descriptions E. histolytica were based on forms of the now encysted state with the food, and which do not degeneration entamoeba, undergo known as E. tetragena. In a recent fatal case of entamcebic in the outside are called any development, except world, dysentery, I found in some preparations, entamoeba: with amcebse. histolytica, nipponica, and tetragena features side by side. Aug., 1913.] PATHOGENIC AND NON-PATHOGENIC AMOEBAE. 329

" I wish to call attention to the very important about them in what literature I could get, but I do not differences in the pictures obtained by staining toith hema- recall that I saw anywhere, and certainly not in the toxylin and Romonowsky. Hematoxylin stains the textbooks of that date, any distinction of species. All refractile granules which are so evident in the nucleus the writers whom I consulted, termed the organisms in the fresh specimen, and these granules are called found associated with dysentery, amoeba: coli. At that chromatin. They are condensed in the centriole, time the Avater-supply was not in its present state of or and in the and amoebae were very found, karyosome ring karyosome substance, efficiency, frequently " peripheral nuclear ring. In Romonowsky preparations, particularly in that class of patients known as Zone it seems to have been customary to call certain structures and also among the human derelicts known as charity,"" within the nucleus and staining a bright purple, chro- beach combers," who were stranded in Colon. and had as matin ; but by carefully differentiating, it will be seen Shortly after I had arrived, become firmly that the purple substance has quite a different distri- convinced as anyone else here as to association of avuuba bution within the nucleus, from that substance which coli with dysentery, those who had become proficient in stains with hematoxylin and is also known as chromatin. the identification of the parasite, claimed that non- It will be seen too that the parts of the nucleus which motile amcebaj could also be distinguished with certainty. stain well with hematoxylin have taken a blue coloration As a corollary the number of cases 0/ amoebic dysentery, in the Romonowsky preparation, and that the structure or rather of amcebic injection diagnosed as amcebic or substance between the centriole and the nuclear dysentery, increased ; in one instance, 300 per cent in two membiane, known as the karyosome ring, stains rather months The number of quinine and thymol irrigations faintly with hematoxylin, but intensely purple in the rose in proportion, as did the sufferings of the patients, polychrome blue eosin preparations. This point should many of whom, if they did not have colitis prior to the not be lost sight of, for it has frequently been the treatment, certainly developed it later. The charts of that occasion of introducing errors into the illustrations and day contained among the stool findings a very high per cent, of in literature for amcebce coli. It is that most of the descriptions protozoa ; example, of fortunate " physicians Dr. Craig's colored drawings of E. histolytica have been did not make a diagnosis unless the amoeba! kickedelse reproduced by Prof. Calkins in black-and-white values, the hospital would have been too small for the treatment thus giving an absolutely erroneous impression of the of other diseases. I know now that many of the non-motile structure of the nucleus. When we consider that amoeba: which, were responsible for a diagnosis and hematoxylin, in black and white, ia the universal treatment of pathogenic injection were cysts of Ent. coli, language, so to speak, used by parasitologists, then with and probably, in some cases, cysts of Ent tetragena also. regard to the points discussed above, the importance of I do not know when the first attempts at a differentia- always explaining whether by chromatin is meant true tion of were made here. Speaking now only is species chromatin or purple chromatin evident." .... for myself, the first time I heard of histolytica was " in In closing, I should like to emphasize one or two when I was on leave in Baltimore 1908 I was asked to points. First, with regard to the errors which hare crept there what method we used distinguish histolytica into the littruture on the subject of entamasbcc by the use from coli. If I remember correctly, I maintained a the of polychrome-eosin stains, and the attempts to describe discreet attitude, and tried to give impression that we life-cycles and appearances of various structures with these found the distinction very difficult. And here I must stains. Careful observation of fresh specimens, compared confess that although 1 must have seen very many with wet fixed hematoxylin preparations, reveals specimens of histolytica and coli between 1006 and 1908, stains that the fact that hematoxylin the refractile substance if any differential appearance they presented struck When these two not what it was. known as chromatin. preparations are my attention, I do remember compared with those stained by Romonowsky, it is seen Since 1908, we have, I believe, tried faithfully to that the nucleus reacts with the stain, so that what is differentiate the two species, and most of us, if not all, stained intensely by hematoxylin is stained feebly recognize (he histolytica as a definite agent in the or not at all with blue in the polychrome-eosin production of dysentery, and the coli as a harmless ; the nuclear commensal. If of with this preparations again, _ portions staining any you disagree statement, purple in polychrome-eosin preparations and called I shall correct it with pleasure, but will not discuss it at chromatin by various writers are entirely difierent from this time, as a full account of arguments 011 this subject hematoxylin-chromatin. can be found in the recent literature. However, our troubles in differentiation, I reqret to say, Dr. James lias also a valuable article 011 the are by no means over. In 19U8 Viereck, and independ- Hartmann and Prowazek, described entamoeba} differentiation of these amoebae from which we ently which Viereck called Entamoeba This as tetragena. must make a few in these of as extracts, days organism resembles in appearance, regards motility emetin treatment the diagnosis of dysentery as and the characteristics of the ectoplasm and endoplasm, follows coli more in its or as amoebic is the histolytica, but closely life bacillary all-important (the At there is as much as to italics are our :? cycle. present dispute own) whether tetragena and histolytica are separate species, or Isthmus are different of the same as' there was "When I came to the in 1906, among the stages organism, stool in to coli and prior to Schaudinn's many other objects in examinations that were regard histolytica to work. and are each almost daily demonstrated my untutored gaze, were Tetragena histolytica^ pathogenic for but in limited with the it small bits of protoplasm that possessed mure or less man, my experience former wa? to virulent. motility. Among these, I told, were amoeba: coli, appears be much less and these were certain manifestations of dysentery, I have given this history, incomplete as it is, of whether or past, present or to come, not the patient amoebic dysentery in the Canal Zone and elsewhere, to time of showed formerly or at the examination any make as plain as I can the imjiortance of identifying symptoms of the disease. There were also in the the entamoeba' in the same manner and under the same specimens other objects which resembled these amcebaj conditions that the malarial parasites are identified. so closely, when the latter were at rest, that the Other species of entamiebie are said to exist in man, and identification might have been said to depend on dysentery is attributed to them. If their identification motility. If the suspected organism threw out pseu- should hold, probably some will be found here also. or as this of is certain that dopodia, "kicked," manifestation activity However this may be, it in the past, as was termed, then I had indisputable proof of the need I have pointed out and on account of the importance of of active treatment and forthwith thymol or quinine the subject will emphasize again, we have treated many in irrigations, or both, were given, most instances to the cases of simple infection with Ent. coli for hypothetical greater discomfort of the patient than of the amoeba?. At it concerns us not to treat I dysentery. present was very much interested in these amoeba, and read simple or complicated infections with this organism for 330 THE INDIAN MEDICAL GAZETTE. [Aug., 1913. true amcebic dysentery, unless pathogenic entamoeba are associated also. Eat coli is found, in health, in diarrhoea, in many diseases not complicated in any way with dysenteric symptoms, and very possibly may be found also in dysenteries that are due to agents, such as the Shiga bacillus, against which it is a waste of time to try bismuth, ipecac, or even quinine and thymol irrigations. On the other hand, very serious results would follow the identification of coli for histolytica. It is true that the persistence of dysentery in such an instance would reveal the true cause of trouble, but such a method of diagnosis, fraught as it is with every possibility of serious complication, cannot be too heartily condemned. Also, histolytica and coli are not infrequently present in the intervals between exacerbations of dysentery, and to take the former for coli with failure to initiate prompt and active treatment, would be a mistake in diagnosis that might seriously impair the patient's health."