CARBON TETRACHLORIDE IN Tg? TREATMENT OF TAENIA INFECTIONS.

By P. A. MAPLESTONE, d.s.o., m.b., cii.B., d.t.m., and

A. K. MUKERJI, m.b. (.From the Hookworm Research Laboratory, Calcutta School of Tropical Medicine and Hygiene. Supported

by the Indian Jute Mills Association.)

Although male fern in one or otfter 01 its

forms is undoubtedly valuable for removing tapeworms from human beings, it has been found relatively inefficient for this purpose in the Calcutta School of Tropical Medicine, where it was used for a considerable period. We accordingly felt the necessity of finding something more reliable.

On searching the literature we found that Allan (1912) reported the cure of three cases of Tcenia saginata infection with a dose of thjnnol given

" in the usual wayArtault (1913) claimed to have cured twenty-three cases with thymol by giving twenty-five centi- grammes every morning for eight days. It was stated that the worm was usually passed on the third or fourth day, but to make

absolutely certain of cure the treatment was continued for eight days. The same treatment and dosage was used by Arnozan (1919), but he only continued it for six days, and he

reported sixty successful cases. These very favourable reports led us to give the above method a trial, and we treated two cases, giving a powder consisting of four grains each of thymol and lactose every morning for eight days. The reason for using lactose with

thymol was that Washburn (1917) found the action of thymol against hookworms was

greatly increased when it was mixed with

lactose, and it would be expected to have the same result in the case of tapeworms. During the course of treatment both patients occasion- ally passed a few segments of worms, in the same way that untreated cases normally do, indicating that the thymol was having appa- rently no effect on the parasites. We therefore did not consider it worth while pursuing this line of treatment further.

Tomb (1923) reported a case in which four treatments with male fern had been unsuccess-

ful, the patient finally being cured by fifteen grains of betanaphthol every morning for ten

days" with a cup of tea and no food until lunch time, and he added that others have also

reported success with this method. We treated two cases following Tomb's directions exactly, and as the results were no better than with

thymol this method was also abandoned. One paper by Daubney and Carman (1928)

and another by Carman (1929) reported very great success in the removal of tapeworms with carbon tetrachloride, so we next tried this

drug. It was thought that preliminary clearing out

of the intestine would probably enhance the

action of the drug, as it is said to do so in the

case of male fern. Therefore when patients were admitted to hospital they were put on Bovril drinks as their sole diet, and were given a saline purge on the two days prior to treat- ment. We also thought it possible that, the

patients being practically starved for two days, the glycogen stored in the liver might be con- siderably reduced, and the toxic action of carbon tetrachloride on this organ might be accentuated accordingly. To counteract this we gave several ounces of sugar syrup during the two days of preparation, with the idea of stocking the liver with glycogen and so pro-

tecting it. Carbon tetrachloride was adminis- tered on the morning of the third day, and it was followed by a saline purgative one and a

668 THE INDIAN MEDICAL GAZETTE. [Dec., 1931.

half to two hours afterwards. The dose of carbon tetrachloride employed was three cubic centimetres for an adult with appropriate reduction for children; the actual dose given to each patient is shown in the table in minims. Nine cases were treated in this way with six

cures, i.e., 66.6 per cent. Although these

figures were encouraging we thought we might get even better results if the carbon tetra- chloride were given in capsules soluble in the duodenum. We treated three patients in this

way, making no difference in the above method except that the carbon tetrachloride was given in soft gelatine capsules instead of being shaken up in water. The first of these patients passed only a few segments after treatment, the second passed no segments for five days after treat-

ment, and the third passed almost the whole worm, and from the subsequent history appears to have been cured. It seems clear from these three cases that giving carbon tetrachloride in capsules does not improve its action, but if

anything rather lessens its efficiency; accord-

ingly no more cases were treated in this way. Up to this time no toxic symptoms whatever

had been exhibited by any of the patients so

it was decided to discontinue the sugar syrup, and, because the simpler a treatment is made the better it is for all concerned, it was

decided to stop the preliminary starvation and purgation as well. The next thirteen cases were admitted to hospital and on the evening of the day of admission they had a meal consist- ing of milk and bread only, and first thing the next morning they were given their dose of carbon tetrachloride shaken up in the saline

purge; thus by this procedure of giving the anthelmintic and purge at the same time the treatment was further simplified. Eleven out

of these thirteen cases were cured?this gives a percentage of 84.6?and the two remaining cases were known to be uncured. If the twelve cases who had preliminary treatment are taken together it is found that seven (or 56.6 per

cent.) were cured, two were not cured, and three were lost sight of. Although the numbers are small it seems evident that the best results are obtained without preliminary treatment.

Daubney and Carman also found that a pre- liminary purge was not an advantage, for they treated a series of twelve prisoners with a dose of castor oil the night before they gave carbon tetrachloride, and eleven of them who remained in gaol long enough to have their stools examined a second time were all found to be still infected. Our total figures since beginning the use of

carbon tetrachloride are twenty-five cases with eighteen (or 72 per cent.) cures, four failures to cure, and three cases lost sight of. Carman and Daubney treated twenty-four cases, mainly with multiple infections, with 31.8 per cent, of cures using carbon tetrachloride alone, and fifty- eight cases with 69.5 per cent, of cures using carbon tetrachloride and oil of chenopodium

together. From these figures they conclude that the two drugs combined are better than carbon tetrachloride alone. We obtained 72 per cent, of cures using carbon tetrachloride alone and in smaller doses than the above workers used, and when we omit the cases that had preli- minary treatment we get 84.6 per cent, of cures. It therefore seems that if oil of chenopodium assists at all its effect is not so great as

Daubney and Carman think. It is true that almost all our cases are infections with a single worm, and that Daubney and Carman in a

series of thirty boys in a reformatory cured 97 per cent, of what they describe as light infec- tions, and they used, as far as can be gathered, carbon tetrachloride without oil of chenopodium. Although their cure rate is somewhat higher than ours it supports the contention that oil of chenopodium does not appear greatly to

increase the number of cures. It appears rather optimistic to look on 97 per cent, as the proved cure rate in light infections of T.

saginata when the result is based on a single series of thirty cases. Taking into considera- tion all Daubney and Carman's figures in con- junction with our own, it seems probable that when more records are available they will show that between 70 per cent, and 80 per cent, of cases of T. saginata infection will be cured by a single dose of carbon tetrachloride, irrespec- tive of whether the infection is single or

multiple. The failure to find scolices does not mean

that a patient has not been cured. The most striking figures illustrating this point are those of the thirty reformatory boys treated by Daubney and Carman, for after the treatment they only found two scolices, but seven weeks later only one of the thirty was again passing tapeworm segments; of the eighteen cases cured by us scolices were recovered in only eight. The reason given by the above authors for the small number of scolices found after treatment with carbon tetrachloride is that the drug kills the worms and so renders them susceptible to digestion. We agree with this interpretation, and the following case illustrates how rapidly digestion of the scolex may occur. A patient was treated at six a.m., and the stool was

received in our laboratory at eleven a.m., ^

was washed immediately and the scolex broken off short from the strobila was found. This was placed on a slide in water and a cover-

glass lightly dropped on top of it without any

pressure, and it was found that the manipula- tion had caused the suckers to fall away fr?nj the head beside which they were lying, and

that the head itself was so softened that it was

quite distorted and ragged looking, and if

had not been for the adjacent suckers with the cavities in the head from which they had fallen away being visible the structure woul have been unrecognizable as a cestode scolex.

Unfortunately during the time male fern was in use the patients were not followed up

an

Dec, 1931.] TREATMENT FOR TAPEWORM: MAPLESTONE & MUKERJI. 669

Results of treatment with male fern and CARBON TETRACHLORIDE.

Carbon tetrachloride.

Number of cases

Number from which scolices w<

recovered.

Number traced and found cured.

Number not traced .

Number not cured ..

asked to report if they had a recurrence of

passing tapeworm segments, so that we do not know how many of the above twenty-one were cured, whereas in the case of the carbon tetra- chloride series there are only three about which we know nothing. It is extremely unlikely that all the unknown cases were cured, but if we accept this possibility we find 76 per cent, of cures with male fern and 84 per cent, of cures with carbon tetrachloride. This estimate

obviously greatly favours the cure rate of male fern with its much greater number of unknowns, and even then the cure rate of carbon tetra- chloride is better by 8 per cent. We therefore feel justified in stating that in our experience carbon tetrachloride is a much more efficient

agent against T. saginata than male fern. Male fern is still practically the universal

remedy against tapeworms in human beings, and although the records of its successful

employment in this connection are very numer- ous in the literature, most of the reports refer to treatment of one or two cases with no refer- ence to failures, so it is impossible to obtain figures of the cure rate with this drug when a large number of cases have been treated with it under similar conditions. Schneider (1926) who strongly advocates the use of a duodenal tube in the treatment of tapeworm infections, as he says the drug is more efficient and can be given in smaller doses by this method, only cured 71.2 per cent, of eighty-seven cases.

This implies that given in the ordinary way male fern cures less than the above percentage. Our cure rate at its lowest estimate is 72 per cent, and that of Daubney and Carman varies between 69.5 per cent, and 97 per cent, for different series of cases, so there seems little

Cases treated with carbon tetrachloride.

No. Age in years.

15

2 3 3 14 4 14 5 30

6 16 7 15 8 48 ?9 16 10 37

11 14

12 15 13 61

14 30 15 14

16 15 17 22

18 35

19 25 20 50 21 28 22 50 23 30 24 35 25 32

Preliminary treatment.

Dose in minims.

Bovril, sugar, pur- gative for 2 days before.

Do. Do. Do. Do.

Do. Do. Do. Do. Do.

Do.

Do. Milk diet prevL ous night. No

purgative. Do. Do.

Do. Do.

Do.

Do. Do. Do. Do. Do. Do. Do.

20

Purgative.

li hours later.

10 Do. 32 1 Do. 32 ; Do. 48 2 hours

J later. 48 Do. 40 Do. 48 i Do. 48 j Do.

32 in capsule 1| hours (in 2 j later,

portions). j 32 in capsule Do.

I 48 in capsule Do.

16

48 25

25 48

48

48 48 48 48 48 48 48

At same time.

Do. Do.

Do. Do.

Do.

Do. Do. Do. Do. Do. Do. Do.

Amount of worm passed.

About half strobila

Whole worm Almost whole worm Whole worm Whole worm

Whole worm Part of strobila only Part of strobila only Part of strobila only Large strobila. Stool not washed.

No segments passed for 5 days after treatment.

Nearly whole worm ..

Whole worm

Almost whole worm ..

Two whole worms (T. solium).

Almost whole worm ..

Two whole worms

Terminal segments only

Almost whole worm ..

Part of strobila only ..

Part of strobila only ..

Part of strobila only ..

Almost whole worm ..

Almost whole worm ..

Whole worm

After-history.

Not known.

Free up to one year.

Not cured. Not known. Free up to 2 months. Not known.

Not cured.

Free up to 6 months.

Free up to 9 months.

Free up to 9 months.

Not cured. Passing seg- ments again.

Free up to 7 months. Not cured. Free up to 7 months. Free up to 6 months. Free up to 4 months. Free up to 2 months.

670 THE INDIAN MEDICAL GAZETTE. [Dec., 1931.

/

doubt that carbon tetrachloride is a better drug than male fern for the removal of tapeworms. Another point is that as we have succeeded in curing at least the same percentage of cases with carbon tetrachloride by the mouth as

Schneider has cured with male fern by the duodenal tube; our form of treatment is pre- ferable because it is much simpler and less irksome to the patient. Indeed, although we have not yet used our method on out-patients because we wished to follow the cases closely for purposes of record in this paper, there is no reason why our latest and most successful method could not be used on these patients.

It will be noted that one of our cases passed two heads of T. solium. This is of some im-

portance as it appears to be the first record of the removal of this species of worm with car- bon tetrachloride, and, although the other drugs used for removal of tapeworms from human

beings act equally well on T. saginata and T. solium, according to Daubney and Carman carbon tetrachloride will remove Avitellina

centripunctata from sheep, but it is useless

against the other cestodes of sheep or against the cestodes of dogs.

Tetrachlorethylene, a drug closely allied to

carbon tetrachloride, has been advocated by some as a better and safer drug than the latter for the treatment of hookworm infections; we tried it on three cases of T. saginata infection, but as no action on these worms was apparent we did not try it further.

References.

Allan, W. (1912). Thymol for Tcenia saginata. Journ. Amer. Med. Assoc., Vol. LIX, p. 197. Arnozan, X. (1919). Thymol for Expulsion of Tape-

worms. Journ. de Med. de Bordeaux, Vol. XC, p. 267. (Review Trop. Dis. Bull., Vol. XVII, p. 69.)

Y* Artault, S. (1913). Le Thymol contre le Taenia. Bull. General de Therapeutique, Vol. CLXV, p. 267. \(Review Trop. Dis. Bull., Vol. I, p. 701.) A. Carman, J. A. (1929). Observations on incidence of

helminthic infestation in natives of Kenya, with special reference to Tamiasis, its effect on nutrition and its treatment with carbon tetrachloride. Journ. Trop. Med. and Hyg., Vol. XXXII, p. 321. Daubney, R., and Carman, J. A. (1928). Helminthic

Infestations of Natives ? in the Kenya Highlands. Parasitology, Vol. XX, p. 185.

?;&- Schneider, H. (1926). Weitere Efarhungen ueber die Bandwurmkur mittels der Duddenalsonde. Miinchener

ijned. Woch., Vol. LXXIII, p. 1403. '?'-Jornb, J. W. (1923). A Treatment for Tapeworm. (Correspondence.) Lancet, Vol. I, p. 1131. Washburn, B. E. (1917). Use of Thymol in Treat-

ment of Hookworm Disease. Journ. Amer. Med. Assoc., Vol. LXVIII, p. 1162.