REPORT OF A CASE OF INDIGENOUS PARASITIC CHYLURIA WITH FI- LARIA NOCTURNA IN THE BLOOD. BY FREDERICK P. HENRY, M.D., OF PHILADELPHIA; PROFESSOR OF THE PRINCIPLES AND PRACTICE OF MEDICINE IN THE WOMAN'S MEDICAL COLLEGE OF PENNSYLVANIA. FROM THE MEDICAL NEWS, May 2, 1898. [Reprinted from The Medical News, May 2, 1896J REPORT OF A CASE 0 F IN DIG E N 0 U S P A R A- SITIC CHYLUR/A WITH FILAJtlA NOC- TURN A IN THE BLOOD.' By FREDERICK P. HENRY, M.D., OF PROFESSOR OF THE PRINCIPLES AND PRACTICE OF MEDICINE IN THE WOMAN'S MEDICAL COLLEGE OF PENNSYLVANIA. Fanny B., married, aged twenty-nine, was born in Columbia, S. C., and spent the first twenty- seven years of her life in that town. Her twenty- eighth year was passed in Palatka, Fla., and her twenty-ninth in Philadelphia, where she arrived in March, 1895. Her father died from sunstroke, and her mother, for several years before her death, suffered from "shingles"-herpes circinnatus. She had the usual diseases of childhood, except scarlatina. At the age of twelve she fell from a fig-tree, and soon after developed a large abscess in the left lumbar region, the site of which is plainly indicated by a cicatrix about three inches long, a little above and parallel with the posterior portion of the crest of the ilium. This abscess continued open for several months, but finally healed. A year after its closure another abscess appeared in the left iliac region, and also pur- sued a chronic course. Its site is indicated by a linear cicatrix, about two inches long, a little above and parallel with Poupart's ligament. The pa- tient suffered from what she vaguely described as an attack of malarial fever in March, 1895, but never manifested any signs of malarial infection while in the South. She has had two miscar- riages: one at four months and a half; the other at two months. Both were ascribed to per- sistent vomiting. Three weeks before her admis- sion to the Woman's Hospital of Philadelphia- she was admitted on February 16, 1896-she gave birth to a child at term. The labor was natural in all respects. Previous to the birth of her child she suffered from pain in the region of the kid- 1 Read at the meeting of the Association of American Physicians, at Washington, D. C., May i, 1896. 2 neys. On the second day of her lying-in this pain became intense and continued for a week, when it abated somewhat. On admission it was still com- plained of. On the third day of her lying-in she passed milky urine, and had difficulty in micturi- tion on account of the occlusion of the urethra with what she regarded as stringy masses of mucus. There were, in reality, coagula of lymph Fig. i. The movement of a single filaria during a series of four suc- cessive instantaneous exposures. The length of each exposure was one-fifth of a second, the entire series occupying less than five seconds. The magnification is to eight hundred diameters, with a Zeiss one-twelfth homogeneous immersion lens. and blood. The urine, after standing for several hours in a narrow, cylindrical vessel, separates into two portions, of which the lower is distinctly hemorrhagic; while the upper, has the appearance of milk or cream. Floating on the upper chylous layer are numerous coagula of a delicate, pinkish hue, and almost translucent, while at the the bot- 3 tom, are a few small blood clots. A little of the urine was shaken up in a test tube with ether and set aside until the urine and ether had separated. The latter being then evaported on a watch-glass, a distinct deposit of fat was obtained. The chy- lous urine contained a trace of albumin, but no sugar, and was free from casts. I found this woman awaiting me at my clinic at the Woman's Hospital on Tuesday, February 18, 1896, and lectured upon her case as one of chyluria, probably parasitic. On the evening of February 19th I visited the hospital for the pur- pose of examining my patient's blood for the filaria sanguinis, taking with me a small microscope and making the search with a half-inch objective. I withdrew the blood from the finger about 10 p.m., and examined several slides without finding the parasite. I left the slides at the hospital, and after my departure one of the resident physicians, Dr. Ida E. Blackburn, examined them with a stronger lens, and fortunately succeeded in de- tecting the filaria. Since then filariae have been found in almost every slide examined. They are not numerous, the maximum number observed on a single slide being five. The urine was repeat- edly examined, the centrifugal machine being used to separate the parasites, but only on one occa- sion were they found in that fluid. With the specimen in which they were detected the centrif- ugal machine was not employed. The filariae have not been found in the milk of the mother or in the blood of the infant, and they are very few in number or absent from the blood of the mother during the day. The variety present in this case is, therefore, the filaria nocturna, the embryo of an adult which isalive in one of the lymphatic channels. The patient was put to bed, and frequent ex- aminations were made of her blood and urine. She was at first placed upon quinin and ergotin, without any apparent effect, the urine continuing chylous and bloody, although in an intermittent manner. February 25th, I examined the blood, and found filariae. I then directed leeches to be applied to the lumbar region, ostensibly to relieve pain, but in reality to test the question whether 4 the leech might play the role of an intermediate host to the filariae. Three of the leeches [were sent to me the next morning. I opened one of the leeches at 10 a.m., and examined its blood. Filariae were abundantly present-one slide con- tained six-and actively moving. The next morn- ing (February 26th) they were still active. The same afternoon I found three dead filariae on one of the slides, and but one still living and languidly Fig. 2. Filaria alive in the blood. Instantaneous photomicrograph. Four hundred diameters magnification. Four millimeters Zeiss apochromatic. moving. At the same hour the filariae removed directly from the body were all living. On Feb- ruary 29th I opened another leech, and found a number of dead filariae in its blood-none living. It appears evident, therefore, that although the filariae may live many hours in the body of the leech, that animal does not play the part of an intermediary host to them. L 5 February 28th, the patient was placed upon thymol (gr. ii. every three hours), and coinci- dently with its administration, the urine became normal in every respect, and so continued for seven days, when it again became chylous and bloody. The filariae during this interval were abundantly present in the blood. March 12th, I ordered methylene blue in two grain capsules every three hours, being induced to do so by the remarkable statements of Dr. Austin Flint, concerning the efficacy of this substance in a case of parasitic chyluria.1 March 13th, 1 found Mrs. B. out of bed and dressed. Her appearance was good, her lips and cheeks being well-colored; urine deep blue; eye- ground examined by Dr. Gertrude A. Walker, ophthalmologist to the hospital, who confirmed my observation as to the abscence of any morbid appearance in the retina. Patient anxious to go home, but persuaded to stay another week. On Saturday evening, March 14th, I obtained some blood from the finger as usual, and exam- ined it the next morning. I had scarcely placed the first slide under the microscope when I de- tected two filariae (in the same field) moving with the greatest activity. I was unable to perceive that the filariae were stained in the slightest degree by the methylene blue which the patient, at the time the blood was withdrawn, had been taking con- tinuously for seventy-two hours. Her urine and feces were stained a deep blue, but the milk was uncolored. Thus far I find no corroboration of Flint's statement that methylene blue stains the filariae in the circulating blood, much less that it exerts any deleterious influence upon them. My experience, although differing from that of Flint, in this matter, is precisely in accord with that of Laveran,2 who found that the filaria perished a few seconds after it was brought into contact with a drop of a solution of quinin, of the strength of 1-1000, while methylene blue (strength of solution 1 New York Medical Journal, June 15, 1895. 2 Bulletins et Mimoires de la Soc. Med. des hopitaux de Paris, 3 serie, tome x, p. 738. 6 not stated) does not hasten their death, and does not stain them until they are dead. March 17th, Mrs. B. came downstairs to my clinic at the Woman's Hospital; specimen of her urine, deeply stained with methylene blue, ex- hibited. Blood was withdrawn from her finger at one o'clock, and seven slides prepared. These were repeatedly examined by myself and an as- sistant, the result being that two filariae were Fig. 3. The same as Fig. 2. Magnified to fifteen hundred diameters. Showing structure and commencing granular degeneration. found in the seven slides. This is the third time in which the blood has been examined by day, namely, once before at one o'clock, when no filariae were found, and once at 8 a.m., when only one was discovered. It is evident that the para- sites are much less numerous in the superficial capillaries by day than by night. This is the sixth day since the treatment with methylene blue was instituted, and the results, thus far, are by no means encouraging. The drug appears to be ab- 7 solutely inert, so far as concerns the destruction of the filariae. Different opinions as to whether or not the filariae were stained, were expressed by those who saw the specimens. The majority thought they were not, but being on the lookout for such staining, I fancied that they had a faint bluish tinge. March 19th, at one o'clock, the patient having been taking methylene blue (two grains every three hours) for one week, I counted the blood corpuscles. Number of red corpuscles per cubic millimeter, 4,100,000; white not increased in number and unstained. Hemoglobin, sixty-five per cent. Five slides of rapidly dried blood were pre- pared, and no filariae found. It is a singular fact that the previous day, while the patient was tak- ing the methylene blue as usual, the urine sud- denly became quite clear and macroscopically normal. I gave two slides of blood to Dr. Alfred Stengel, of the Pepper Laboratory of Clinical Medicine (University of Pennsylvania), in order to obtain his opinion as to whether or not the leucocytes were stained with the methylene blue, which the patient had been taking continuously in full doses for more than one week at the time the blood was withdrawn. Dr. Stengel reported that he could find no evidence of blue discoloration of the corpuscles. March 20th, at nine o'clock in the evening, I prepared a number of slides. The filariae were abundantly present. I found them in eighteen out of twenty-one preparations, and, as I did not use a mechanical stage, it is possible that I may have overlooked them in the three slides, in which the search was ineffectual. The serum of the blood was decidedly blue, and the filariae of an exceedingly delicate bluish tinge. The methylene blue had been taken by the patient continuously in full doses for nine days and had proved absolutely inert, so far as any influence upon the vitality of the embryos is concerned. March 21st, the patient returned to her home. I omitted to state that shortly after the pa- 8 tient's admission I had her vaccinated on the theory that an intercurrent infection might de- stroy the parasite. The vaccination was per- fectly successful, but quite as useless from a therapeutic standpoint as the methylene blue. The above case is of special interest both be- cause it is the first of the kind observed in Phila- delphia, and also for the reason that it adds an- other to the list of those indigenous to the United States. It is impossible to say how long the filarial embryos have been circulating in the blood of this patient, but it is in the highest de- gree probable that the infection occurred either in South Carolina or Florida, and it is not im- possible that the lumbar and inguinal abscesses, from which she suffered at the age of twelve, were due to the filariae. Similar abscesses form part of the clinical history of filariasis. The exciting cause of the chyluria was probably the rupture of a dilated lymphatic during the expulsive pains of labor. The supposition that infection occurred at the age of twelve or earlier necessarily implies the circulation of the embryos in the blood for many years without giving rise to symptoms. In connection with this question of the innocuous presence of the filariae in the blood of men the following case is of interest: In the autumn of 1893,3 well-known physician of Philadelphia consulted me about his son-in-law, who had resided for some years in Columbia, S. C., and latterly near Tampa, Fla. Filariae were said to have been found in his blood by de Saus- sure of Charleston. Up to the time I speak of the symptoms had been those of intestinal indi- gestion, consisting chiefly of great abdominal dis- tress, meteorism, irregular action of the bowels, great nervous excitement at times, especially to- ward evening. I examined the patient's blood in vain for the filariae, and Professor Guiteras, who examined it twice, was equally unsuccessful. The 9 time of my examination was about io p. m. , and I have since thought that my failure to detect the parasite may have been due to the fact that the patient walked to my office. The gentleman in question returned to his home in Florida, and a few months later passed chylous urine for the first time. The chyluria continued for one or two months, and has not returned. Of late the patient has been in a fair state of health, and free from the intestinal symptoms above-mentioned. Post-mortem examination, of those who have perished from parasitic chyluria, has revealed enormous distention of the lymphatic vessels of the urinary tract, and sometimes also of the thor- acic duct. A few months ago, I exhibited before the Philadelphia County Medical Society a speci- men of chyluria from a Cuban, whose blood I vainly searched for the filaria. I had but one opportunity of examining the blood of this man, and for that I was indebted to Dr. Charles W. Coburn, who was in attendance upon the case. Shortly after my examination the man died and an autopsy was held under very unpropitious cir- cumstances. There was, however, no difficulty in ascertaining that the lymphatic vessels, especi- ally those of both renal regions, were enormously dilated and convoluted, many of them being of the caliber of an ordinary lead pencil. The dila- tation was most marked on the right side, and in the pelvis of the corresponding kidney there was a pale lymph clot similar to the coagula passed with the urine during life. In this case it is greatly to be regretted that a careful dissection with a view to the detection of one or more of the adult filariae was not possible. The time at our dis- posal was limited, and the light was derived from a single lamp which was held by turns by Dr. Coburn and myself, the autopsy being skilfully performed by Dr. Bundy of the Woman's Medical College of Pennsylvania. 10 The importation of a case of filariasis into a city of the latitude of Philadelphia naturally raises the question whether the disease may become en- demic therein, and there seems to be no good reason why it should not. The brilliant researches of Dr. Patrick Manson have established the fact that the mosquito plays the part of an intermedi- Fig. 4. Tail of filaria showing sheath extending beyond the apparent end of the tail. Eight hundred diameters. ary host in conveying the filaria nocturna from man to man. At night the embryos swarm to the surface, while during the day they retire to the deeper vessels. Acting upon this knowledge, Manson exposed a filaria patient to the bites of mosquitos, and found the embryos in the bodies of these insects, in which, in the course of from 11 five to seven days, they attain a length of one- fifteenth of an inch. In the blood of man, they measure from to of an inch, and are enclosed in a sheath, from which they make their escape in the viscid blood of the mosquito. The mos- quitos with the embryonic filariae in their interior seek water in which to deposit their eggs. This function accomplished, they perish; the embry- onic filariae are liberated, and, through the medium of the water in which they exist, gain access to the human system. One or more of the ingested parasites attains maturity in the lymphatic system and continues for an indefinite period (in some cases for many years) to produce swarms of em- bryos. The latter being but of an inch in diameter, readily traverse the lymphatic glands, and reach the blood vessels via the thoracic duct. It is through the plugging of the lymphatic ves- sels, especially those connected with the urinary tract, that the lymph and chyle become mingled with the urine. For further details concerning the life history of this parasite, and the mode in which it occludes the lymph channels, the reader is referred to the writings of Manson.1 In Philadelphia, mosquitos are abundantly pres- ent during the summer and autumn, and have convenient access to the Schuylkill River, from which our water supply is derived. The chance of a given individual becoming infected through the medium of a river of the volume of the Schuylkill is doubtless infinitesimal, but no one acquainted with the wonderful vitality of the em- bryonic filaria can deny its possibility. The surest safeguard against this and other sources of infec- tion is filtration. The filaria nocturna is now known to be indig- 1 Especially the articles in Davidson's " Hygiene and Diseases of Warm Climates"; International Clinics, April, 1895; "Transac- tions of the International Congress of Hygiene and Demography," Seventh Congress, 1891. 12 enous in Europe, as appears from the report of a case recently studied by M. Font of Spain.1 The patient was a man, thirty-five years of age, who had resided all his life at Canet de Mar, with the exception of a short period passed at San Sebastian and Vitoria. Canet de Mar is a town of 5000 inhabitants on the shore of the Medit- erranean, in latitude 410 37' north, between Bar- celona and the French frontier, and is a favorite retreat for veteran sailors, many of whom have visited the West India Islands. Dr. Ballester, in a communication to Font, reports having seen in the same town two cases of hematochyluria dur- ing fourteen years, in neither of which was there an examination of the blood. In Font's case the presence of the filaria nocturna was repeatedly demonstrated. Thus far three species of filaria have been cer- tainly detected: (1) Filaria diurna, (2) Filaria nocturna, (3) Filaria perstans. These names are indicative of the habits of the animal, the filaria diurna being found in the superficial vessels solely or chiefly during the day; the filaria nocturna solely or chiefly during the night; while the filaria perstans is constantly present in the capillaries of the integument. The filaria diurna and the filaria perstans are confined, thus far, to the west coast of Africa and adjoining districts; while the filaria nocturna is pandemic in the tropics and endemic in certain sections of the United States. The adults of filaria nocturna have been frequently found; that of filaria perstans never, so far as I have been able to ascertain. In the opinion of Manson, the filaria loa of the eye of the negro of Old Calabar is probably the adult form of the filaria diurna. If it is not, he argues, then there must be another blood worm yet to be discovered, for 1 Revista de Ciencias Medicas de Barcelona, 25 February, 10 Marzo, 1894. 13 the embryos of the loa must escape from the body of their host through the medium of the circula- tion. The filaria perstans has been practically proved by Manson to be the cause of the fatal " sleeping sickness" of the Congo region. While engaged in writing this article my atten- tion was called by Dr. Charles A. Oliver of Phila- Fig. 5. Head of living filaria. The blur in front of the head is probably due to'the motion of cilia. Fifteen hundred diameters. delphia, to a remarkable case of filaria loa, re- cently reported by Dr. Argyll Robertson. The patient was a lady who had spent eight years in missionary work at Old Calabar on the West coast of Africa. Without enteringinto the details of this interesting case I will merely state that in two suc- sessive operations Dr. Robertson extracted two filaria (variety loa) from the ocular tissues, the 14 first a male, the second a female. Both of these adult parasites are described by Manson in the course of Robinson's paper. The female was stuffed with embryos, but repeated examinations of the blood failed to detect any embryonic filariae in that fluid. The latter fact certainly seems to refute Dr. Manson's hypothesis that the filaria loa is the adult form of the embryonic filaria diurna. In a letter recently received from Dr. Manson, he says that America possesses the "unenviable distinction of possessing a filaria of the blood, which is possibly peculiar to itself. I found it in negroes from the island of St. Vincent, and I have little doubt but that it could be found in the negroes of the more tropical States of the Union. This filaria I have named Filaria Demarquayi, after Demarquay, the dis- coverer of filaria nocturna. It is a very small worm, not half the size of the filaria you are familiar with. It observes no periodicity; it is sharp-tailed, and it possesses a sheath," etc. This Filaria Demarquayix should, therefore, be added to the list above given, so that, at the present time, there are four distinct varieties of filaria sanguinis hominis. The steps by which our present knowledge of the filaria nocturna has been obtained were grad- ual. The embryo was first discovered by Demar- quay in 1863 in the liquid of a chylous hydro- cele; next, in the blood by T. R. Lewis of India, in 1872. In 1876, the adult parasite was found in a lymphatic abscess of the arm by Bancroft of Brisbane, Australia, and is accordingly, known to helminthologists as the filaria Bancrofts this name having been assigned to it by Cobbold. Finally, our knowledge of the life history of the parasite has been completed by the genius of Manson We are irresistibly reminded of the analogous 1 I would suggest that the last-mentioned parasite would be much more appropriately called filaria Mansoni. 15 history of the discovery of trichiniasis, with which the names of Hilton, Paget, Owen, Leidy, and Zenker are associated. In the United States filariasis can no longer be considered as an extremely rare disease, and it is probable that it is more prevalent in certain of our Southern States than is suspected. Pro- fessor John Guiteras, of the University of Pennsylvania, was the first to demonstrate the existence of endemic parasitic chyluria in this country,1 and de Saussure' of Charleston, has published the clinical histories of twenty-two cases of filariasis observed in Charleston, S. C., from 1886 to 1890. Two cases of filariasis indig- enous to Virginia have been reported by Dr. R. M. Slaughter,3 but in neither of them was the blood examined. In both there was hemato- chyluria and filariae in the urine, and in one filariae were found in the pus of an alveolar ab- scess. While I believe these cases of Dr. Slaugh- ter to be genuine examples of filariasis, I can- not refrain from the criticism that the illus- tration accompanying his paper bears but a su- perficial resemblance to the embryonic filaria nocturna. Another indigenous case is reported by Dr. C. W. Mastin of Mobile, Ala.,4 the patient being a young man, age twenty-two, who had never been outside o.f Mobile and its immediate vicinity. In Mastin's case the filarious lesion was a chylous hydrocele. The filaria is also said to be have been found by Weiss in the urine of a child who had never been out of Illinois.5 I am by no means sure that I have collected all the reported cases of indigenous filariasis; in fact, I have made no 1 Medical News, April io, 1886. 2 Medical News, June 28, 1890. 'Medical News, Septembers, 1891. 4 Annals of Surgery, 1888, vol. 8, p. 320. 6 American Text Book of the Diseases of Children, Starr. 16 attempt to do so. Sufficient, however, has been said to show that the disease is widespread and not confined to tropical and sub-tropical regions. In this connection I may remark that the em- bryonic filaria nocturna is capable of great resist- ance to cold. My slides, prepared in winter and kept in a cold room, showed the parasites active Fig. 6. Shows the head of a filaria overlapping a red corpuscle. The appearance might readily be mistaken for the cephalic end of a sheath. Magnified eight hundred diameters. at the end of six or seven days; in fact, one lived for ten days. Exposure for many hours to a freezing temperature does not kill them, as proved by one of the methods employed by Manson to demonstrate "filarial ecdysis." This consists in placing the slide containing the filariae upon a 17 block of ice overnight, in order to cause a sepa- ration of hemoglobin from the red corpuscles. The effect of this degree of cold is to render the movements of the animal somewhat languid, but after withdrawal from the ice they become as ac- tive as before, and the embryos speedily escape from their sheaths. Facts such as the above seem to prove that nothing but time is needed for filariasis, the scourge of certain tropical countries, to become prevalent in our own, and demonstrate the vital im- portance of municipal filtration of our water supply. I have said little about treatment in the fore- going remarks because I do not believe there is any drug capable of destroying adult filarige in the human system. Surgeon-major E. Laurie of Hy- derabad, reports two cases which he believed to have been promptly cured by thymol,1 the maxi- mum dose being five grains twice daily. Walsh, of the general hospital of Calcutta, also reports success from the use of thymol. On the other hand, Crombie, of the same institution, has given two hundred grains of thymol daily in one case, and forty-five grains daily in another, without pro- ducing any effect upon the worms. As the lat- ter justly remarks, "thymol is so exceedingly in- soluble that it is improbable that any apprecia- ble quantity of it left the intestinal canal."2 I consider it a very fortunate circumstance that the case of Fanny B. came under my observation at a time when I was able to secure the co-opera- tion of such an expert in photomicrography as Dr. Charles Lester Leonard, whose arduous work has been pursued in the Laboratory of Hygiene of the University of Pennsylvania. The ap- pended illustrations are all photographs of the living parasite, and this is, I believe, the first time in which 1 Lancet, February 14, 1891 2 Lancet, August 13, 1892. 18 the living filaria have been photographed under a one-twelfth oil immersion lens, or, so far as I am aware, under any. The representations are, there- fore, absolutely accurate, and necessarily take precedence of any drawings of the living or photo- graphs of the dead nematode. To show the fal- lacy of drawings, I may say that one artist pic- tured the worm with long cilia waving from its head, while another was unable to see anything of the sort in the same specimen. I may say, in this connection, that I am inclined to believe in the existence of such cilia, although they are not shown in the photographs; unless they are indicated by the blur in Fig. 5. The point I wish to emphasize is that nothing can be repre- sented in the photographs that was not present at the time they were taken. I may say also that I have been unable to de- tect the "cephalic armature " described by Man- son, although the "pouting" movement of the head was plainly visible. In mentioning my in- ability to detect the cephalic spine, or fang, I have no intention to impugn the accuracy of Manson's description. I attribute my failure en- tirely to my deficient training in this line of research. In conclusion, I wish to express my thanks to Dr. Anna M. Fullerton, the distinguished physi- cian in charge of the Woman's Hospital of Phila- delphia, and to her assistants, Drs. Blackburn and Carpenter, for their kind and skilful co-opera- tion with me in my study of this interesting case. Postscript.-I visited Fannie B. at her home on March 25th, and found her in good condition, she informed me that since leaving the hospital, her baby's feces have been stained blue. She is taking ten grains of methylene blue daily-two grains every three hours. March 28th, patient's milk now faintly stained blue. Treatment continued. 19 March 29th, visited the patient this evening and prepared eleven slides, in every one of which I found filariae in most active movement. She has now been taking methylene blue since March 12th. From the 12th until the 21st, the dose was two grains every three hours-sixteen grains per diem-and from the 21st until the 29th, it has been ten grains a day, in divided doses of two grains. The drug, in this case, has proved abso- lutely inert. The patient's urine is deeply stained, and her milk very slightly stained. The baby's fecal discharges are blue, and his urine also of a faint bluish tint. Filariae of a very faint bluish tinge. Leucocytes unstained. A few filaments of cotton on the different slides were stained of a faint bluish tint by the blood plasma with which they were in contact. From the above it is manifested that my ex- perience with methylene blue in parasitic chyluria is entirely different from that of Austin Flint and Joseph N. Henry.1 The latter in his report to Flint says: " The effects of methylene blue in this case were de- cided and prompt. After the administration of two grains every two hours during the day on March 5th, the parasites were very few at 11 p.m. ; the only two found were deeply stained with blue, and their movements were extremely sluggish, the urine being clear but intensely blue. On the fourth and seventh days no parasites were found, although the treatment had been discontinued after the first day. On the eighth day, the urine became milky, and on the night of the ninth day, filariae were found in great number, but their movements were not very active. On the tenth day, the treatment was re- sumed, and continued for five days. Three days after, the blood being examined at night, a very few motionless filariae were observed. Since that time and up to the present writing, the urine has been normal and the patient has been restored to perfect health." Admitting the disappearance of the parasites in Joseph N. Henry's case, I believe it to have been a. mere coincidence and in no way related to the x New York Medical Journal, June 15, 1895. 20 administration of methylene blue. I have given this drug in larger doses than were used in the case reported by Flint, and for a much longer period, without the slightest effect upon the parasite. The Medical News. 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