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ordinary characters of early atrophic cirrhosis ; there was nofungus. ITwo other specimens of mycetoma were also examined.

’’

One, an amputated foot, was kindly sent by Surgeon-MajorParakh. ’Sections of a muscle were cut from this specimen,and they showed the muscle to be excavated so that only ashell remained, whilst within the cavity the fungus wasfound. Many round cells of inflammation were foundaround the fungus, and the muscle was greatly degenerated.The other specimen, also a foot, was sent by Dr. Nanavatiof Ahmedabad. Sections of a subcutaneous fungus nodulewere cut from this, and showed characters similar to thosedescribed above.

I have to acknowledge the assistance of Dr. N. F. Sllr-

veyor of Bombay. The sections were prepared by theparaffin method, fixed with Mayer’s albumen, and stainedwith various reagents.Remarks by Surgeon-Major HATCA.-I have seen about

fifty cases of mycetoma in all stages in the foot, lower partof the leg, and hand. Progress has always been extremelyslow, painless, and the bones invariably affected andreduced to a papery condition. Diagnosis has never pre-sented much difficulty, except quite in the early stage whencommencing in the big toe or hand. The present case is

unique in my experience-the great size of the limb, thenumerous projections on the surface, the infiltrated conditionof the soft parts (giving a resemblance to elephantiasis), thevery rapid progress, and the absence of bone affection beingespecially remarkable. Secondary deposit in the glands ofthe groin is not uncommon, but I have never before metwith enlargement of the pelvic glands. Unfortunately, thepatient being so ignorant, it was impossible to get any clueas to the origin of the disease. The post-mortem notes weremade by Surgeon-Captain Childe and Dr. Surveyor, who hasmade some valuable researches on mycetoma.

THYMOL AS AN ANTHELMINTIC.BY PROSPERO SONSINO, M.D.,

OF PISA.

THE history of a large number of the substances from timeto time proposed as remedies is generally the following.A certain drug is suggested as a remedy for a particulardisease ; after some hesitancy its virtues are extolled bynumerous observers from all parts of the medical world, butas yet only as against the original disease. Then its reputedefficacy is little by little extended to many other ailments, andin a short time it is recommended in a large number of casesand diseases. Afterwards a reaction against its use arises,and its drawbacks are pointed out ; and, lastly, after a longtime has elapsed, its true therapeutical place is settled onsure ground, provided it does not eventually fall into com-plete disuse and oblivion. It seems that thymol is now

passing through this common ordeal. Thymol was used firstoy Bozzolo in 1880 for ankylostomiasis. After some waveringats efficacy was confirmed by many practitioners, and it isnow regarded as the best remedy against ankylostomiasis, sothat it has generally superseded liquid extract of male fern,the only other remedy which for some time could competewith it. But the efficacy of thymol in the treatment ofankylostomiasis was not yet well confirmed when it was alreadybeing tried in other ailments, and especially as a generalanthelmintic ; and now, if the assertions of some hastyeulogisers are to be trusted, it is the best remedy against allintestinal worms, tænia included, and also against thehæmatozoon filaria sanguinis hominis. I think it reflectsgreat credit on Surgeon-Lieutenant-Colonel Crombie ofCalcutta to have settled that about ten grammes per diemof thymol, given for three successive days, have not availedto cause the disappearance of the embryo filarica from theblood, contrary to what has been asserted by others-viz.,that daily doses of some fraction of a gramme of this samedrug, taken for a certain number of days, were sufficientto cure radically filarial disease. Bat it seems to me thatSurgeon-Lieutenant-Colonel Crombie has been too hasty inasserting that thymol, while inefficacious as against filaria3anguinis, is effective against the intestinal worms, tsenia

1 THE LANCET, Oct. 13th, 1894.

included. I hope to obtain permis,ion to record in THELANCET the result of my experience on this subject.

Whilst I have had numerous brilliant successes from

thymol in the treatment of ankylostomiasis, so that I canassert that in this disease it often acts like a charm, I mustconfess that there are some cases-rare, it is true-inwhich I really found difficulty in ridding the intestines ofankylostoms even by means of this remedy. I now have acase of this kind under treatment, a case which, after all, issurely not one of simple ankylostomiasis. Although in thiscase the administration three times daily of doses of fourgrammes brought away in all thirty-one ankylostoms, never-theless the stools still contain eggs of this parasite in asgreat abundance as they did previously to the thymol treat-ment, and as plentifully as they are found in the stools ofpatients in which thymol brings away hundreds of ankylo-stoms. I cannot explain on sure grounds the cause of thisnon-success, but I argue that it may be due to the circum-stance that a certain number of worms are still hidden in thewalls of the intestine or under the folds of the valvulasconniventes in such a manner that the thymol may pass themwithout displaying its deadly action on them. It may bealso simply that, being enveloped in an extraordinary abund-ance of tenacious mucus, they are shielded from the actionof the drug. These rare cases of non-success must notdetract from the reputation of thymol as an admirable remedyin the treatment of ankylostoma ; but I wish to insist thatits efficacy as against ankylostomiasis cannot in any mannerwarrant the profession to generalise and to proclaim it as aremedy against all other intestinal parasites without adducingpositive proofs of such efficacy in the case of each species ofworm. Now I am sure that the only worms I have some-times seen expelled along with ankylostoma after the admini-stration of thymol are ascaris lumbricoides, oxyuris vermicu-laris, and trichocephalus dispar; but, while expulsion ofankylostoma is the rule with thymol, this drug acts on theother worms only exceptionally, and in the greater number ofcases it altogether fails to e:Eect their expulsion. In thisway, for the expulsion of ascaris lumbricoides and oxyurisvermicularis I cannot trust to thymol any more than I canto other ordinary remedies in use, such as santonine (or,better, the new drug, santoninissina) in the case of theformer, and the enema of quassia amara or vinegar in that ofthe latter. As for trichocephalus, it is well known that thereis great difficulty in obtaining its expulsion by any remedy.Consequently. after my first trials, in which I found insome cases trichocephali in the stools following the adminis-tration of thymol, I entertained the hope that the new drugmight prove to be an efficacious remedy against this worm.The ordinary seat of trichocephali being the caecum I sug-gested that their expulsion might be assured by usingthymol as an enema ; but as this means that thymolmust be given in solution, I fear that it could not beused in such doses as to be efficacious as an anthel-mintic without proving hurtful to the host by absorp-tion. Indeed, thymol introduced into the circulation is

certainly a poison, even in small doses, and if one venturesto give it in such large doses as four, six, eight, andeven ten grammes per diem, it is only because it is adminis-tered in powders, and it can be relied upon that if everabsorbed it will only be in the minutest proportion. A

symptom of dangerous absorption is afforded when the

patient presents vertigo or delirium. These unpleasantsymptoms are met with only in rare cases after administra-tion of such doses as four grammes of thymol. From what Ihave said, I think that thymol wiil not prove to be so sure aremedy against the three nematodes named as it is againstankylostoma.As for the tasnia, I have never tried thymol against tsenia.

solium or tsenia, medio-canellata, because there exists in

pelletierine, when properly used, the be-t known remedyagainst the large tapeworms ; but I can say that in cases ofankylostomiasis with tsenia nana I did not obtain with thymolthe expulsion of the latter. This was brought about onlyafter recourse was had to ethereal extract of male fern,together with calomel. I must add that I have not yetread of well ascertained cases of expulsion of large tape-worms by means of thymol, and I would be grateful toSurgeon Lieutenant-Colonel Crombie or to any other practi-tioner if they would publish such cases with full particulars,if they know of any. This point is of great importance,because I think it a great therapeutical mistake to cons’derthat a substance which is efficacious in the treatment of oneparticular parasite must also prove successful as a general

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anthelmintic. Experience teaches the contrary as to everysubstance which has been found to have any actionon some species of worm. So also as to thymol, 1can assert that it is generally an efficacious agent in thetreatment of ankylostoms, but very uncertain in thecase of the other three nematodes named and entirelyinefficacious against tænia nana. A single case of expulsionof only an isolated specimen of distomum crassum (recordedlately by Dr. J. H. Walker in Sandakan Hospital, BritishNorth Borneo) by small doses of thymol is not sufficient toestablish on sure ground the general efficacy of this remedyin treating the large Asiatic fluke.With regard to the method of administering thymol, I think

that the best way to give it is in powder, enclosed in wafersor cachets. I find that tabloids are not of any advantage,because they must be given in numbers too great for con-veniently administering doses of several grammes, and thatthe direct contact of the drug with the mouth may prove tobe hurtful, seeing that it is an acid remedy.

PERNICIOUS ANÆMIA.REPORT OF 126 CASES OF THAT DISEASE TREATED DURING

1893 IN THE REWA DISTRICT OF FIJI.

BY C. T. W. HIRSCH, M.R.C.S. ENG., L.R.C.P. LOND.,L.S.A.,

DISTRICT MEDICAL OFFICER OF REWA, FIJI.

PERNICIOUS ANAEMIA appears to be chiefly encountered intropical climates. Under the name of the "beri-beri of

Ceylon " it is very common in that colony, and accounts for250 deaths per million. In Guiana as chloro-anæmia (theAati wati of the natives), or cachexia aqueuse, it is prevalent,and often ends fatally from anasarca and exhaustion, asdoes also a similar disease in North Borneo known as

the "wet beri-beri." In Brazil, Singapore, Senegal, andMauritius it occurs as one of the fatal sequelæ of malarialfever. The diagnof,is was, as Dr. William Hunter pointedout in a paper on this subject, read recently before theHarveian Society of London, commonly arrived at by aprocess of exclusion, it being held that no anasmia couldbe termed pernicious unless it could be proved not to

belong to any of the other and better-known forms ofanaemia. Dr. Hunter and others have recently greatly addedto the knowledge of this subject-the diagnosis now beingbased on a consideration of the changes in the blood, thecharacter of the urine, and associated changes pointing todisturbance of liver function. The cases which I propose inthis paper to briefly discuss are confined to Indian immi-grants residing and working on sugar plantations in theRewa district of Fiji. These estates are all situated alongthe Rewa River, and consist chiefly of alluvial flats of fromeighty to 1500 acres, which extend from the river bank backto and in between the hills, of which there are many. Theclimate is exceedingly humid. The following table gives themeteorological observations as taken at Nausori plantation :-

The rainfall is considerably higber on other estates, the fall for the year at Naitasiri being 16587in., while at Viria it I

2 Brit. Med. Jour., Dec. 5th, 1891. Two cases of beri-beri associatedwith distomum crassum, &c.

was 141’29 in. Altogether 126 cases of pernicious anæmia,were treated. Of these, forty-one died, thirty-four were

returned to India as chronic invalids, twenty-five are still;under treatment, and the remaining twenty-six have returnedto work, though a considerable number are still weak andbut classed as fit to perform a limited task. The method ofinquiry pursued was to keep a tabulated history of eachindividual case, and especially to investigate such points andsymptoms as were noted by Dr. William Hunter in his paperson this subject. To save space, and what would have beenin many cases useless repetition, I have not included withthis a table of cases, but have given full statistical informa.-tion in the text. There were ninety-eight males and twenty-eight female patients. Perhaps, however, this preponderance-of the male sex is to some extent due to the fact that moremale than female immigrants are introduced. In 1892 thenumbers were 977 men as compared with 403 women. As.regards the previous history and habits of the patients, as manyas forty were, I was assured by the overseers and hospitalattendants in charge of them, dirt-eaters ; and these gentlemenalso stated that they were of opinion that a great many ofthe coolies had similar tastes, which, as a rule, they gratified.The general opinion among planters and their Europeanassistants is that coolies eat dirt so as to make themselvesill and thus be liberated from labour ; I fear, however,that the occupations of the overseers and hospital attendants.render them somewhat suspicious of all who state that

they are sick, and that they may be prone to imputebase and even groundless motives to anything that mayprevent their men from working. But, without doubt,a few may eat dirt with that object in view, and a greatmany, I believe, do so because they have a longing for some-thing more than rice, and cannot, on account of their

religion, eat meat, and are unable to procure fish, and toe.poor to indulge in fowls. Clay is the substance commonlyeaten, though occasionally smithy coals are partaken of. Itis extremely difficult to get any trustworthy account of theprevious health of the majority of the cases. Some eightystated that they had had, at some time or other, fever-

According to the hospital books, forty-eight had been previously (in Fiji) admitted for gastric disturbance and thirtyfor slight pyrexia. In nine cases there was a clear history ofsyphilis. The symptoms of the disease seem to be invariablyinsidious in onset. Gastric disturbance with slight diarrhcea.is first complained of, and in 110 cases was the first symptomto be noticed ; in twenty-one there was also vomiting. In

ninety-four slight icterus was remarked. In all ansemia was, ofcourse, most intense, and such symptoms, referable to a generalanaemic state, as venous hum about the neck, bruit de diable.haemic murmurs in the praecordial region, palpitation, vertigo,and occasional tendency to syncope were noted in almost allthe cases. Breathlessness is usually most pronounced, and insixty-seven cases was noted as being to a slight degreepresent even when the patient was at rest. In only sevencases did there appear to be organic valvular disease, and’the mitral valve was the one always affected. Hæmorrhagescertainly did not seem to be as general as text-books wouldlead one to infer. Four cases of metrorrhagia were noted,and though the hospital attendants were charged to examinethe stools melaena was but perceived occasionally in sometwenty of the cases. Eight showed on ophthalmoscopicexamination signs of retinal hsemorrhage. None sufferedfrom either epistaxis, haemoptysis, baematemesis, hæmaturia,or purpuric skin eruptions. Dropsy occurred in fifty-onecases. General anasarca, with ascites and oedema of thebases of the lungs, was a common precursor of death,and was noted in thirty-one of the forty-one fatal cases.

Paracentesis abdominalis had frequently to be resorted toin order to relieve distension and pressure on importantorgans ; the fluid in all cases, however, reaccumulatedvery rapidly. Slight puffiness of the eyelids and ankles,was observed in many of the cases. The urine in ninety-si?:cases was unusually dark in colour, and though in five caseson microscopic examination blood pigment was detected innone were any corpuscles to be recognised. In four case&albumen was present. In none was sugar found, thoughsearch for it had always to be made because of the generalhigh specific gravity. Indican was found in twenty-twocases, Jaffe’s and Senator’s tests being employed. In thetropics the amount of indican appears usually to be increased.Unfortunately it was impossible to examine specimens ofthe blood in all the cases; a certain number were, how-ever, submitted to microscopic investigation, and the whit6-corpuscles were noted to be very numerous, and often