SUPPLEMENT 689 



communicated by Schiller, 1 an Ascaris had gained access to the 

 biliary passages after an operation for cholelithiasis (with distension 

 of the gall-bladder and formation of a fistula) ; it had kept itself alive 

 here eighteen days and was extracted from the fistulous opening. 

 Epstein 2 confirms the correctness of the explanation of the mark of 

 strangulation in an Ascaris in Mertens' 3 case (in a woman, aged 30, 

 there was first icterus, later ascites, anasarca, swelling of the liver, 

 then the discharge of two dead Ascaridcv, one of which exhibited a 

 constriction somewhat behind its centre ; after that there was rapid 

 improvement in all the symptoms) ; in his case there was icterus in 

 consequence of closure of the ductus choledochus by an Ascaris. 

 After the discharge of the worm the symptoms persisted ; one of the 

 Ascaridcv had a typical strangulation mark. From the observation 

 recorded by Vierordt 4 it follows that, without doubt, mature females 

 can penetrate into the liver and there deposit egi^s ; in addition, that 

 such egf*s appear exceptionally to undergo segmentation. A unique 

 feature in this case consisted in the exclusive discharge of immature 

 worms almost regularly throughout an interval of nine weeks ; this 

 cannot be explained from our present knowledge of the biology and 

 pathology of the Ascaridcv. These worms clearly make their way from 

 the intestine outwards, through the opening into the duodenum of 

 the common bile-duct, and unquestionably the fully developed 

 Ascarides, with the aid of their conical head end, are enabled gradually 

 to penetrate the wall of the ductus choledochus (Quincke 5 ), and gain 

 access to the gall-bladder, the hepatic duct and its branches. 



The changes in the biliary passages and the liver are, on the one 

 hand, the mechanical results of a partial or total obstruction to the 

 flow of the bile, and, on the other, of inflammatory processes. The 

 blocking of the common bile-duct and of the trunk of the hepatic 

 duct leads to the well-known symptoms of biliary engorgement ; 

 protracted continuance of this condition has, as its sequela, general 

 distension of the whole biliary system and degenerative destruction 

 of the liver-cells. If the Ascaris is situated at some other part of the 

 biliary system, its presence causes a partial arrest of the flow of bile, 

 with the corresponding sequelae. Many Ascarides perish in the ductus 

 choledochus, and here and in the gall-bladder they may supply the 

 nucleus of a gall-stone ; deeper in the liver this does not appear to 

 happen ; the dead Ascaridce here undergo a kind of maceration, dis- 

 integrate, and may be completely absorbed; in many cases the worms 



1 Schiller, Beitr. zur klin. Chir., IQO2, xxxiv. 



- Epstein, Deutsch. Arch. f. klin. Med. t 1904, Ixxxi. 



3 Mertens, Detttsch. med. Wochenschr . , 1898, xxiii. 



4 Vierordt, Volkmann's Samml. klin. Vortr., No. 375. 



3 Quincke, " Nothnagel's Spez. Path. u. Therap.," 1899, xviii. 



