FURTHER notes on the prevalence OF ANKYLOSTOMIASIS, OR THE DOCHMIUS DUODENALIS. By Surgeon-Major Edwin Dobson, mb., Civil Surgeon, Dhubri.
submitted in continuation"of have appeared in the Indian iny Medical Gazette from December 1892 to March The numbers in which the parasites 1893. These
notes are
notes which
were fouud in each case are
now stated with the of "thread-worms." The reason for my having adopted this procedure is due to a note made by the Sanitary Commissioner of Assam on a report submitted to him by me on ankylostomiasis in 1892, wherein lie says: "Dr. Dobson's tables do not per se indicate swarms of auchylostomum in healthy persons, as anehylostoma only is written in the remarks in all such cases except in the table page 54, where 'lotsol anehylostoma' are mentioned in the remark opposite cuse No. 5 in that table." The word "lots," I may add, appeared against this one case quite by accident, but it is as well that this accident did occur; as a matter of fact, "lots of anehylostoma" were found in numbers of healthy coolies. The omission or inclusion of an indefinite word or phrase in an inquiry
sin'gle exception
where
we
aim
at
something definite.is, however, Hence the reason why I
scarcely justifiable.
mention only the fact whether existed or not in the cases examined, but by au oversight the word "lots" appeared in my report against this one case.
had tried
to
anehylostoma
Aug.
1893.]
DOBSON ON THE PREVALENCE OF THE DOOHMIUS DUODENALI8.
The word has, however, I think, been the means of doing good rather than harm. This remark of the Commissioner's also led me to ask a medical subordinate what he meant a
Sanitary
by
vague statement of "hundreds" which he had recorded two cases he had examined in
against
the Dhubri dispensary, and which were included in my previous notes. His answer is as follows: " The word < hundreds' was used where the number appeared to be many (may be 20, may be 100 or so)." This then, I may add, only confirms what I have already said as to how careful
we should be to make definite statements only, and I might also add to see things for ourselves. In the notes now submitted, but absolute
facts
nothing
recorded. The only two tables regarding which I have accepted a hospital assistant's statements are those referring to Goal para dispensary and Goalpara jali. But here the parasites found were sent to me daily, and some of the cases were seen by me. The hospital assistant, I may add, was specially qualified to make the inquiry, and is a thoroughly reliable subordinate, and invariably carries out any defiuite instructions he may receive. With these introductory remarks, I now state the result of my inquiries. as seen
by myself
are
Every
person who was experimented on rethymol in two doses of thirty grains each at about 9 and 10-30 in the moruing, aud if an immigrant, he was shipped on board the Assam mail steamer at about 4-30 the same evening, a Bo that any stools passed after this hour as result of a thymol treatment could not be examined. These immigrants invariably had their breakfast somewhere between 12 and 1 o'clock in the day. I selected 605 of the healthiest looking of the coolies who arrived here with the intention of executing labour-contracts for Assam, and whenever practicable, I selected persons coming from different places in India. Of the 605 cases, 21 had no action of the bowels before they left Dhubri for Assam, and in 29 others, the action of the bowels was insufficient, and 8 cases vomited the drug, so that it is fair to exclude these 58 cases from the 605 cases. This then reduces the cases to 547; numthis among ber 70 had no parasites, 366 had the anchylostoma alone, 88 had the anchylostoma, together with other parasites, and 23 had other parasites, but no anchylostoma. In other words, we find the anchylostoma present in no less than 454 of the 547 cases. ceived
In the 88 cases where the anchylostoma existed with other parasites, the details are given below:? 11 cases had anchylostoma with round worms (five of these cases had 1 round worm; two cases
had 2 round worms; two had 3 round worms; one case had 8 round worms; aud one case had 13 round worms.)
263
4 cases had anchylostoma with rouud and thread-worms (one of these cases had 2 round
worms; one case had 3 round worms; and two 61 cases had cases had 1 round worm each.) anchylostoma with thread-worms. 1 case had 60 anchylostoma with 1 round worm, thread-worms, 150 flukes about the size of a florin, flat and of a fleshy colour when fresh, and tape-like in thickness, and 20 small flukes half the size of one's little finger nail.) The above was from A.zimghur, in the North-West Provinces, and the results obtained from this very healthy man rather surprised us. 10 cases had anchylostoma with
tape-worms. 1 case had anchylostoma with tape and thread-worms. Of the 23 cases in which no anchylostoma were found, the following details are given:? 18 cases had thread-worms only. 2 cases had rouud worms ouly (one of these cases had 1 round worm only, and the other had 2 round worms). 1
had tape-worm only. 1 case had tape and one round worm. 1 case had threadworms and three small flukes. This case was a Rajput coolie from Manbhoom. Thirty-three coolies were rejected for anjemia (the so distinguished beri-beri), and gave the results:? Eighteen coolies had anchylostoma alone. 7 had anchylostoma with thread-worms. 1 had anchylostoma with tape-worm. 1 had thread5 had no worms only. 1 had tape-worm only. parasites at all?So that the anchylostoma was found in 26 out of the 33 cases. Forty-two coolies were rejected for enlarged spleen, and gave the following results :? 21 had anchylostoma alone. 5 had anchylostoma with thread-worms. 1 had anchylostoma with one trichocephalus dispar. 4 had auchylostoma with round worms (two of these cases had each 1 round worm, and one case had 2 round worms, and one had 4 round worms.) 11 had no parasites at all?So that anchylostoma was found iu Sl out of the 42 cases. Twenty-one coolies were rejected for other causes, and gave the following results :? 13 had anchylostoma alone. 3 had anchylostoma with thread-worms. 2 had anchylostoma with round worms (in one case 2 round worms, and iu the 'other, 10 round worms), 2 had thread-worms ouly. 1 had no parasites at all? so that the anchylostoma was found in 18 out of the 21 cases. I must here add that one case among the 13 with anchylostoma alone suffered from an enlarged spleen, anaemia, and general dropsy of abdomen, face, and of legs as high as knees only. This case had 139 anchylostoma. I have considered it fair to show this case case
worm
following
under "other causes," and give these at the same time.
particulars
Among the rejected coolies 3 with enlarged spleen had no action of the bowels, 2 with
INDIAN MEDICAL GAZETTE.
264 1 with ulcer of the
anaemia,
leg,
and 2 with bad
physical development had insufficient action, and
so these 8 cases have been excluded from the total rejections. Fifteen seemingly healthy coolies who executed contracts in districts of recruitmeut, and were passed by medical men to labour in Assam, were, on arrival at Dhubri, submitted to thymol, and gave the following results:? Two of these cases were from Lohardagga, in one anchylostoma was found, and the other case had no parasites at all. Three of these cases were from Hazaribagh, and all had the anchylostoma, in one of them thread-worms were also found. Ten of these cases were from Ganjam, in Madras, all had the anchylostoma. In one of these ten cases, thread-worms also were found. These ten coolies were the only ones from Ganjam who passed through Dhubri during the last four months. In my previous report I stated " the anchylostoma seem almost to occupy a normal habitation in the Nepaulese, and the stronger and healthier-looking he happens to be the more numerous seem to be the number of the parasites." During the past four months only one batch of Nepaulese coolies consisting of 13 souls passed through the Dhubri depots, of these 11 were given thymol; one of the eleven had no parasites, and on one the drug did not act; one case had 2 round worms only, aud another had thread-worms only. The remaining seven cases had 31, 52, 6, 12, 60, 13, and 13 anchylostoma individually; and in the third and the sixth of these, it existed with thread-worms. These Nepaulese are included in the tabular statement attached, which accouuts for the number of anchylostoma in each healthy cooly. Fifty-eight peons known to me personally for several years, who accompany immigrants from the recruiting districts to Dhubri were given thymol; one had no action of the bowels; in three it was insufficient; aud one vomited the drug, so that by excluding these five, the number was reduced to 53. Among this number 22 had no parasites of any kind. 23 had the anchylostoma alone; aud in three others it existed with thread-
In four cases thread-worms alone existaud in one case there was a single trichoce-
worms.
ed,
phalu3 dispar.
Nineteen clerks and managers of the Dhubri depots took thymol with the following results : Six had no parasites of any kind. Among this number was one Eurasian and one European. The seventh case vomited the drug. The eight case (an Eurasian) had one round worm, cases The remain9 aud 10 had thread-worms only. ?
ing
nine
worm
anchylostoma.
In
one
of
thread-worms existed with the iu the second, thread-worms, and existed with the auchylostoma;
cases
anchylostoma; X rouud
had
cases
these nine
[Aug.
1893.
there were 4 round worms with anohylostoma. The above persons were natives of Dacca, Hooghly, Birbhum, Backerguuge, the 24-Pergunnalis, Arrah, and Jounpur, and were Brahmins aud Kayests by caste. One of these which had three anchylostoma had never left Burisal, in Backergunge, till eleven days pre-
aud iu
a
third,
viously.
Nine topazes, natives of Chapra, employed at the Dhubri depot for periods ranging from five to two years, gave the
following results :? 2 had thread-worms only, 1 had tape-worm only, the remaining five had anchylostoma : but in three of these cases the tape-worm existed with anchylostoma. All the clerks and topazes have been here for several years, aud are in excellent health. Twenty-three prisoners in the Dhubri jail, 21 of whom were in perfect health, gave the follow1 had
no
parasites,
ing results:?
5 had no parasites. 10 had anchylostoma alone. 3 had anchylostoma with thread-worms. 1 had anchylostoma with 43 small flukes. 1 had anchylostoma with thread-worms aud one rouud worm also. 1 had one round worm alone, and 2 had thread-worms alone?So that the anchylostoma existed in 15 of the cases. Among the 23 prisouers one was iu indifferent health and had only thread-worms, aud another, who had a slightly enlarged spleen aud was a native of Dhubri, had but one anchylostoma, aud 43 small flukes; 42 of these flukes were obtaiued the day following the administration of thymol, but not till after castor oil and sautonine had been given. Santouine and castor oil was given to 15 of these prisouers the day following the giviug of thymol, but additional results were ouly obtained iu three cases. In one 5 anchylostoma were expelled, making the total number 18, aud iu another case, in which thymol had given no parasites, one
round
worm was
expelled.
Thirteen prisoners in the Goalpara jail, 11 of whom were in very good health, gave the following results:? 4 had anchylostoma alone. 4 had anchylos1 had anchylostoma toma with thread-worms. with thread-worms and 2 round worms. 1 had anchylostoma with thread-worms and one trichocephalus dispar. 3 had no parasites at all?So that 10 had the auchylostoma. Two of the prisoners were in indifferent health, one of whom had no parasites at all, but the other had 25 anchylostoma and thread-worms. Of the 23 prisoners in the Dhubri jail, four belonged to Bengal
stations, viz., Faridpur, Ranchi, Jalpigori, and Cooch Behar. The Jalpigori case had no parasite
the Faridpur case had 23 anchylosThe Ranchi case had 1 round worm, and the Cooch Behar case had 7 anchylostoma and
of any
kind,
toma.
thread-worms. A fifth
case was
from
Mirzapore
in the North-
West Provinces aud had 5 anchylostoma. Of the
Aug.
1893.]
DOBSON ON THE PREVALENCE OF THE DOCHMIUS DUODENALIS.
265
remaining
and 1 round worm. Of the 34 cases, no less than 30 had the anchylostoma, 3 had no parasites, and 1 which had rouud worms alone was a kala-
the$kala-azarj)ortious
azar case.
18 cases, one belonged to Sibsagar, in ami had no parasites of any kind, and the other 17 belonged to Dhubri, but not from of this district. Of the 13 prisoners in the Goalpara jail, one was a native of Faridpur, in Bengal, and had 3 auchylostoma with thread-worms and 2 round worms. A second came from Amritsar, in the Punjab, and had 7 auchylostoma only, and the remaining 11 belonged to the kala-azar portions of this district. Thirty-four indoor patients were admitted into the Goalpara dispensary between 18th December 1892, and 9th February 1893. Every case got 60 grains of thymol in two doses of 30 grains each at intervals of 1^ hours as soon after admission as the patient's health permitted of such, and the usual treatment for the diseases for which they were admitted was also carried out. Among the 34, 3 only had no parasites, aud of these 2 were cases of kala-azar aud 1 of ague. The total number of kala-azar cases was 15, 5 of these had'the auchylostoma alone in the following numbers 2,26, 8, 3 ami 12; in four others there was one with 3 auchylostoma aud 3 round worms; another with 6 auchylostoma and 2 round worms; a third, with 36 auchylostoma aud 3 round worms; and the fourth, with 7 auchylostoma and 2 rouud worms. In another 6 auchylostoma with thread-worms and 2 round worms were found; iu another, 6 auchylostoma with thread-worms; and iu another, 6 auchylostoma with 60 large and 19 small flukes ; this latter was iu a boy aged 14 who had been all his
Assam,
years,
lifetime iu Barpeta, in the Gauhati district, and had ouly just come to Goalpara. Iu one kalaazar case 13 round worms alone, but uo auchylostoma
were
found. The
two
beri-beri
cases
had
auchylostoma respectively. The latter was not admitted by Surgeon-Colonel Cos-
31 aud 8 case
tello and myself to be beri-lwi at all, but the hospital assistant gave his rcasuus for thinking otherwise.
The
two ulcer cases had iu one of them 4
in the other alone. The two chancre cases had in one of tlfem thread-worms and 4 anchylostoma, and in the other 22 auchylostoma and 13 round worms. The 4 ague cases had parasites iu ouly three of them, viz., 7 anchylostoma aud 21 rouud worms in one; 23 anchylostoma, thread-worms, aud 2 rouud worms in the second; and iu the third, 8 auchylostoma aloue were
anchylostoma with thread-worms, and
3
auchylostoma
found. The
two
diarrhoea
cases
had 22 aud 5
anchy-
respectively. The contusion case had 6 auchylostoma alone. The two bronchitis cases had 7 and 17 anchylostoma respectively. The lostoma
rheumatic case had 5 anchylostoma, threadworms, and 15 round worms. The phymosis case The asthma case had 4 had 23 anchylostoma. auchylostoma and thread-worms, and the dysentery case had 4 auchylostoma and thread-worms,
All the 15 kala-azar cases were typical of the and the complications were more or less marked. Iu all of them emaciation was a leading symptom; 11 had no anaemia, 3 had it well marked, and one had it slightly so. The spleen was much eularged in 14 cases, and slightly so in the remaining one. There was no dropsy ot auy kind iu 10 of the cases, but it was present iu the five remaining cases in the feet and face; 13 of the 15 cases had a distinct fever history, and iu 11 of them it was recorded by the^ thermometer.
disease,
The
the Goalpara cases admitted into for other diseases except kala-azar, had the symptoms usually met with under their several diseases. The 2 beri-beri cases, it will be noticed, both had anaemia, but were not emaciated, and one of them had slight fever. Tliey had 31 and 8 anchylostoma respectively. One diarrhoea case had slight fever, extreme emaciation, but no oedema, aud had 5 anchylostoma; the second diarrhoea case had slight anaemia, and oedema of face and feet, and 22 anchylostoma. The dysentery case had slight anaemia, general dropsy, 4 anchylostoma, threadOne of the ague worms, and 1 rouud worm. cases was taken ill en route from Pubua, in Bengal to Goalpara, and had 8 anchylostoma. Among the 30 indoor patients admitted into the Dhubri dispensary between December 1892, and February 1893, 19 had the anchylostoma; six had other parasites; and five had no parasites at all. The following are the details:? 19
dispensary
Dysentery, chancre, synovitis, caries of bone, and contused wound were the five cases with no parasites of auy kind. Five others had round worms alone, viz., one remittent fever with diarrhoea; two with malarial cachexia; oue with dropsy of feet, legs and upper limbs; and one with dislocation of the shoulder, and these worms were present in the following numbers 2, 5, 5, 1, aud 1. Another a case of malarial cachexia in a boy aged 12 years, who belonged to Gauhati, but who had lived for three years within six miles of Dhubri had 10 large and 42 small flukes. Thread-worms, with one anchylostoma, existed in a kala-azar case. Ten cases had the anchylostoma by itself aud in the following numbers: 2 beri-beri with 3 aud 4 anchylostoma in each; a kala-az ar case had the ova of the anchylostoma; one a buminuria with ascites had 12 anchylostoma; one dysentery case had 2 anchylostoma. Three malarial fever cases had each 1, 50, and 5 anchylostoma respectively; one debility had 11 anchylostoma; one malarial cachexia had 105
anchylostoma.
34
266
The
INDIAN MEDICAL GAZETTE.
following eight
with rouud
cases
had
anchylostoma
worms; one diarrhoea had 22 anchylostoma and 2 round worms. Three dysentery
had 5, 4, and 7 anchylostoma coupled with 6, 12 and 4 round worms; oue ague had 24 anchylostoma and 9 rouud worms; one beri-beri had 5 anchylostoma and 4 round worms; one malarial fever had 22 anchylostoma and 3 rouud worms; aud oue case, with urinary fistula?, had 11 auchylostoma aud 3 round worms. Iu 16 of the Dhubri dispensary cases, santouiue and castor oil was given on the morning following that on which thymol was giveu; in 12 of these cases no more parasites were obtained, but iu two dysentery cases which gave only 2 auchylostoma in one, and 7 anchylostoma with one round worm in the other: the sautonine and oil uext day brought away 12 rouud worms with 2 auchylostoma and in the second case, 3 round worms only. In an ague case, which originally gave 12 anchylostoma, the santouiue aud oil accounted for 12 more auchylostoma aud 9 rouud worms ; and the fourth case that of urinary fistulae, which originally gave, 11 anchylostoma and 1 round worm, the sautouiue and oil accounted for 2 more round It is possible the parasites, removed by worms. the castor oil aud sautonine, were really on their way out as a result of the previous day's
thymol.
The two kala-azar cases had no anEemia, but had greatly enlarged spleens, one had oedema of feet, but the other had no signs of dropsy. The two beri-beri cases had ausemia but no enlargement of spleen. I admit we see a certain number of cases of intense anannia, at times coupled with dropsy which may be general or partial and, which we unhesitatingly say, is beri-beri, or the "antenna of coolies," but a reference to the tabular statement attached will show that though the anchylostoma may be found in these cases, we find the parasites as frequently and iu quite as great uumbers in others who are absolutely healthy, or have enlarged spleens, or are suffering from diseases with which we know the auchylostoma can have no possible connection, and further, we have the fact demonstrated beyond doubt of its extensive, I might almost add its universal, prevalence all over India as shown in tlie tabular statement followiug, which gives names of the districts aud provinces from which immigrants have come, and iu whom the anchylostoma were The immigrants coming into Assam found. prove this. They are all persous who come from their homes straight into Dhubri after a jouruey of two or three days only, and they are The here submitted to the thymol treatment. Dhubri the of district indigenous population the parasite equally prevalent seem to have among them, and the cases from Pubua, Backerto iu this gunge, aud Cooch Behar referred
report
clearly
[Aug. show the
1893.
exists in the I further think
parasite
districts.
neighbouring Bengal the theory put forth that the Cacharies, Kabhas, Garos, &c., have contracted the disease because of their going in search of work on tea-gardens for some months in the year, where they mix with the imported tea-garden coolies is certainly
far as the inhabitants of the kalaof the Dhubri district are conI am not aware that these people seek cerned. work at all on tea-gardens in Upper and Central Assam. My inquiries, I contend, justify the belief that it has yet to be proved that the anchylostoma is the cause of the kala-azar of this district. Even in cases of so-called beri-beri, is the presence of the anchylostoma in them, convincing evidence that they alone cause the disease and in the way suggested. I think not ! The trichocephalus dispar is evidently not common among immigrants on their arrival in this district in Assam. My previous notes showed this parasite, and the round worm to be very common among the dispensary patients in the Gauhati dispensary. The coolies rejected by me for anaemia, I should consider typical cases of beri-beri. I find my medical subordinates consider " beri-beri to be aniemia without any other complication except the anchylostoma, even though one parasite is found. Kala-azar to be enlarged spleen with no anaemia, malarial cachexia to be an enlarged spleen with anaemia," and with the result of our recent investigations before us, I cannot see that they are altogether The vital statistics for Dhubri district wrong. for 1892 show anchylostoma divided into two heads, kala-azar and beri-beri, and 792 and 14 deaths respectively are shown under each subHow this diagnosis has been arrived at head. the by village chowkidars, I am at a loss to understand? The articles on beri-beri and endemic malarial fevers in Chevers's diseases of At page India are worthy of close attention. 67 he refers to an epidemic of beri-beri fever in 1880 at Dacca, Sylhet, and at Shillong, the head-quarters of the Assam Government, Circular No. 32-S of 26th October 1888, from Dr. Lethbridge, Inspector-General of Jails,
not
proved,
azar
Bengal,
may
so
portions
to
Superintendents, subsidiary jails,
be of interest in connection
inquiry.
I need
scarcely
add
that the
with
this
investigations
embodied in this report have occupied a very considerable amount of time and labour, and in
carrying them out, I have been careful to see that everything herein recorded is absolute fact. Whether the anchylostoma produce beri-beri or kala-azar which diseases are considered by Surgeon-Major Giles to be one and the same disease, is, I think, a question still to be settled. If Surgeon-Major Giles is right, then the inter esting point is at what stage aud when does the
Aug.
1893.]
VAUGHAN ON A CASE OF SNAKE-BITE.
; for I have shown how in 'kala-azar' cases it is often not found, and when found, exists frequently in very small numbers ; in true beri-beri, it is very often found in trifling numbers, and again in absolutely healthy persons it is found in great numbers. I have had no opportunities for making any post-mortem examinations since the investigations embodied in these notes were It is rumoured a begun. German Professor will proceed to the districts where kala-azar is prevalent, in order to make observations on the disease. I trust the statement will prove correct and help to clear up the question. I might add that I have sent half the anchylostoma and flukes found by me to the Principal of the Calcutta Medical College for acceptance on behalf of the College Museum.
parasite become injurious
267
submitted in continuation"of have appeared in the Indian iny Medical Gazette from December 1892 to March The numbers in which the parasites 1893. These
notes are
notes which
were fouud in each case are
now stated with the of "thread-worms." The reason for my having adopted this procedure is due to a note made by the Sanitary Commissioner of Assam on a report submitted to him by me on ankylostomiasis in 1892, wherein lie says: "Dr. Dobson's tables do not per se indicate swarms of auchylostomum in healthy persons, as anehylostoma only is written in the remarks in all such cases except in the table page 54, where 'lotsol anehylostoma' are mentioned in the remark opposite cuse No. 5 in that table." The word "lots," I may add, appeared against this one case quite by accident, but it is as well that this accident did occur; as a matter of fact, "lots of anehylostoma" were found in numbers of healthy coolies. The omission or inclusion of an indefinite word or phrase in an inquiry
sin'gle exception
where
we
aim
at
something definite.is, however, Hence the reason why I
scarcely justifiable.
mention only the fact whether existed or not in the cases examined, but by au oversight the word "lots" appeared in my report against this one case.
had tried
to
anehylostoma
Aug.
1893.]
DOBSON ON THE PREVALENCE OF THE DOOHMIUS DUODENALI8.
The word has, however, I think, been the means of doing good rather than harm. This remark of the Commissioner's also led me to ask a medical subordinate what he meant a
Sanitary
by
vague statement of "hundreds" which he had recorded two cases he had examined in
against
the Dhubri dispensary, and which were included in my previous notes. His answer is as follows: " The word < hundreds' was used where the number appeared to be many (may be 20, may be 100 or so)." This then, I may add, only confirms what I have already said as to how careful
we should be to make definite statements only, and I might also add to see things for ourselves. In the notes now submitted, but absolute
facts
nothing
recorded. The only two tables regarding which I have accepted a hospital assistant's statements are those referring to Goal para dispensary and Goalpara jali. But here the parasites found were sent to me daily, and some of the cases were seen by me. The hospital assistant, I may add, was specially qualified to make the inquiry, and is a thoroughly reliable subordinate, and invariably carries out any defiuite instructions he may receive. With these introductory remarks, I now state the result of my inquiries. as seen
by myself
are
Every
person who was experimented on rethymol in two doses of thirty grains each at about 9 and 10-30 in the moruing, aud if an immigrant, he was shipped on board the Assam mail steamer at about 4-30 the same evening, a Bo that any stools passed after this hour as result of a thymol treatment could not be examined. These immigrants invariably had their breakfast somewhere between 12 and 1 o'clock in the day. I selected 605 of the healthiest looking of the coolies who arrived here with the intention of executing labour-contracts for Assam, and whenever practicable, I selected persons coming from different places in India. Of the 605 cases, 21 had no action of the bowels before they left Dhubri for Assam, and in 29 others, the action of the bowels was insufficient, and 8 cases vomited the drug, so that it is fair to exclude these 58 cases from the 605 cases. This then reduces the cases to 547; numthis among ber 70 had no parasites, 366 had the anchylostoma alone, 88 had the anchylostoma, together with other parasites, and 23 had other parasites, but no anchylostoma. In other words, we find the anchylostoma present in no less than 454 of the 547 cases. ceived
In the 88 cases where the anchylostoma existed with other parasites, the details are given below:? 11 cases had anchylostoma with round worms (five of these cases had 1 round worm; two cases
had 2 round worms; two had 3 round worms; one case had 8 round worms; aud one case had 13 round worms.)
263
4 cases had anchylostoma with rouud and thread-worms (one of these cases had 2 round
worms; one case had 3 round worms; and two 61 cases had cases had 1 round worm each.) anchylostoma with thread-worms. 1 case had 60 anchylostoma with 1 round worm, thread-worms, 150 flukes about the size of a florin, flat and of a fleshy colour when fresh, and tape-like in thickness, and 20 small flukes half the size of one's little finger nail.) The above was from A.zimghur, in the North-West Provinces, and the results obtained from this very healthy man rather surprised us. 10 cases had anchylostoma with
tape-worms. 1 case had anchylostoma with tape and thread-worms. Of the 23 cases in which no anchylostoma were found, the following details are given:? 18 cases had thread-worms only. 2 cases had rouud worms ouly (one of these cases had 1 round worm only, and the other had 2 round worms). 1
had tape-worm only. 1 case had tape and one round worm. 1 case had threadworms and three small flukes. This case was a Rajput coolie from Manbhoom. Thirty-three coolies were rejected for anjemia (the so distinguished beri-beri), and gave the results:? Eighteen coolies had anchylostoma alone. 7 had anchylostoma with thread-worms. 1 had anchylostoma with tape-worm. 1 had thread5 had no worms only. 1 had tape-worm only. parasites at all?So that the anchylostoma was found in 26 out of the 33 cases. Forty-two coolies were rejected for enlarged spleen, and gave the following results :? 21 had anchylostoma alone. 5 had anchylostoma with thread-worms. 1 had anchylostoma with one trichocephalus dispar. 4 had auchylostoma with round worms (two of these cases had each 1 round worm, and one case had 2 round worms, and one had 4 round worms.) 11 had no parasites at all?So that anchylostoma was found iu Sl out of the 42 cases. Twenty-one coolies were rejected for other causes, and gave the following results :? 13 had anchylostoma alone. 3 had anchylostoma with thread-worms. 2 had anchylostoma with round worms (in one case 2 round worms, and iu the 'other, 10 round worms), 2 had thread-worms ouly. 1 had no parasites at all? so that the anchylostoma was found in 18 out of the 21 cases. I must here add that one case among the 13 with anchylostoma alone suffered from an enlarged spleen, anaemia, and general dropsy of abdomen, face, and of legs as high as knees only. This case had 139 anchylostoma. I have considered it fair to show this case case
worm
following
under "other causes," and give these at the same time.
particulars
Among the rejected coolies 3 with enlarged spleen had no action of the bowels, 2 with
INDIAN MEDICAL GAZETTE.
264 1 with ulcer of the
anaemia,
leg,
and 2 with bad
physical development had insufficient action, and
so these 8 cases have been excluded from the total rejections. Fifteen seemingly healthy coolies who executed contracts in districts of recruitmeut, and were passed by medical men to labour in Assam, were, on arrival at Dhubri, submitted to thymol, and gave the following results:? Two of these cases were from Lohardagga, in one anchylostoma was found, and the other case had no parasites at all. Three of these cases were from Hazaribagh, and all had the anchylostoma, in one of them thread-worms were also found. Ten of these cases were from Ganjam, in Madras, all had the anchylostoma. In one of these ten cases, thread-worms also were found. These ten coolies were the only ones from Ganjam who passed through Dhubri during the last four months. In my previous report I stated " the anchylostoma seem almost to occupy a normal habitation in the Nepaulese, and the stronger and healthier-looking he happens to be the more numerous seem to be the number of the parasites." During the past four months only one batch of Nepaulese coolies consisting of 13 souls passed through the Dhubri depots, of these 11 were given thymol; one of the eleven had no parasites, and on one the drug did not act; one case had 2 round worms only, aud another had thread-worms only. The remaining seven cases had 31, 52, 6, 12, 60, 13, and 13 anchylostoma individually; and in the third and the sixth of these, it existed with thread-worms. These Nepaulese are included in the tabular statement attached, which accouuts for the number of anchylostoma in each healthy cooly. Fifty-eight peons known to me personally for several years, who accompany immigrants from the recruiting districts to Dhubri were given thymol; one had no action of the bowels; in three it was insufficient; aud one vomited the drug, so that by excluding these five, the number was reduced to 53. Among this number 22 had no parasites of any kind. 23 had the anchylostoma alone; aud in three others it existed with thread-
In four cases thread-worms alone existaud in one case there was a single trichoce-
worms.
ed,
phalu3 dispar.
Nineteen clerks and managers of the Dhubri depots took thymol with the following results : Six had no parasites of any kind. Among this number was one Eurasian and one European. The seventh case vomited the drug. The eight case (an Eurasian) had one round worm, cases The remain9 aud 10 had thread-worms only. ?
ing
nine
worm
anchylostoma.
In
one
of
thread-worms existed with the iu the second, thread-worms, and existed with the auchylostoma;
cases
anchylostoma; X rouud
had
cases
these nine
[Aug.
1893.
there were 4 round worms with anohylostoma. The above persons were natives of Dacca, Hooghly, Birbhum, Backerguuge, the 24-Pergunnalis, Arrah, and Jounpur, and were Brahmins aud Kayests by caste. One of these which had three anchylostoma had never left Burisal, in Backergunge, till eleven days pre-
aud iu
a
third,
viously.
Nine topazes, natives of Chapra, employed at the Dhubri depot for periods ranging from five to two years, gave the
following results :? 2 had thread-worms only, 1 had tape-worm only, the remaining five had anchylostoma : but in three of these cases the tape-worm existed with anchylostoma. All the clerks and topazes have been here for several years, aud are in excellent health. Twenty-three prisoners in the Dhubri jail, 21 of whom were in perfect health, gave the follow1 had
no
parasites,
ing results:?
5 had no parasites. 10 had anchylostoma alone. 3 had anchylostoma with thread-worms. 1 had anchylostoma with 43 small flukes. 1 had anchylostoma with thread-worms aud one rouud worm also. 1 had one round worm alone, and 2 had thread-worms alone?So that the anchylostoma existed in 15 of the cases. Among the 23 prisouers one was iu indifferent health and had only thread-worms, aud another, who had a slightly enlarged spleen aud was a native of Dhubri, had but one anchylostoma, aud 43 small flukes; 42 of these flukes were obtaiued the day following the administration of thymol, but not till after castor oil and sautonine had been given. Santouine and castor oil was given to 15 of these prisouers the day following the giviug of thymol, but additional results were ouly obtained iu three cases. In one 5 anchylostoma were expelled, making the total number 18, aud iu another case, in which thymol had given no parasites, one
round
worm was
expelled.
Thirteen prisoners in the Goalpara jail, 11 of whom were in very good health, gave the following results:? 4 had anchylostoma alone. 4 had anchylos1 had anchylostoma toma with thread-worms. with thread-worms and 2 round worms. 1 had anchylostoma with thread-worms and one trichocephalus dispar. 3 had no parasites at all?So that 10 had the auchylostoma. Two of the prisoners were in indifferent health, one of whom had no parasites at all, but the other had 25 anchylostoma and thread-worms. Of the 23 prisoners in the Dhubri jail, four belonged to Bengal
stations, viz., Faridpur, Ranchi, Jalpigori, and Cooch Behar. The Jalpigori case had no parasite
the Faridpur case had 23 anchylosThe Ranchi case had 1 round worm, and the Cooch Behar case had 7 anchylostoma and
of any
kind,
toma.
thread-worms. A fifth
case was
from
Mirzapore
in the North-
West Provinces aud had 5 anchylostoma. Of the
Aug.
1893.]
DOBSON ON THE PREVALENCE OF THE DOCHMIUS DUODENALIS.
265
remaining
and 1 round worm. Of the 34 cases, no less than 30 had the anchylostoma, 3 had no parasites, and 1 which had rouud worms alone was a kala-
the$kala-azarj)ortious
azar case.
18 cases, one belonged to Sibsagar, in ami had no parasites of any kind, and the other 17 belonged to Dhubri, but not from of this district. Of the 13 prisoners in the Goalpara jail, one was a native of Faridpur, in Bengal, and had 3 auchylostoma with thread-worms and 2 round worms. A second came from Amritsar, in the Punjab, and had 7 auchylostoma only, and the remaining 11 belonged to the kala-azar portions of this district. Thirty-four indoor patients were admitted into the Goalpara dispensary between 18th December 1892, and 9th February 1893. Every case got 60 grains of thymol in two doses of 30 grains each at intervals of 1^ hours as soon after admission as the patient's health permitted of such, and the usual treatment for the diseases for which they were admitted was also carried out. Among the 34, 3 only had no parasites, aud of these 2 were cases of kala-azar aud 1 of ague. The total number of kala-azar cases was 15, 5 of these had'the auchylostoma alone in the following numbers 2,26, 8, 3 ami 12; in four others there was one with 3 auchylostoma aud 3 round worms; another with 6 auchylostoma and 2 round worms; a third, with 36 auchylostoma aud 3 round worms; and the fourth, with 7 auchylostoma and 2 rouud worms. In another 6 auchylostoma with thread-worms and 2 round worms were found; iu another, 6 auchylostoma with thread-worms; and iu another, 6 auchylostoma with 60 large and 19 small flukes ; this latter was iu a boy aged 14 who had been all his
Assam,
years,
lifetime iu Barpeta, in the Gauhati district, and had ouly just come to Goalpara. Iu one kalaazar case 13 round worms alone, but uo auchylostoma
were
found. The
two
beri-beri
cases
had
auchylostoma respectively. The latter was not admitted by Surgeon-Colonel Cos-
31 aud 8 case
tello and myself to be beri-lwi at all, but the hospital assistant gave his rcasuus for thinking otherwise.
The
two ulcer cases had iu one of them 4
in the other alone. The two chancre cases had in one of tlfem thread-worms and 4 anchylostoma, and in the other 22 auchylostoma and 13 round worms. The 4 ague cases had parasites iu ouly three of them, viz., 7 anchylostoma aud 21 rouud worms in one; 23 anchylostoma, thread-worms, aud 2 rouud worms in the second; and iu the third, 8 auchylostoma aloue were
anchylostoma with thread-worms, and
3
auchylostoma
found. The
two
diarrhoea
cases
had 22 aud 5
anchy-
respectively. The contusion case had 6 auchylostoma alone. The two bronchitis cases had 7 and 17 anchylostoma respectively. The lostoma
rheumatic case had 5 anchylostoma, threadworms, and 15 round worms. The phymosis case The asthma case had 4 had 23 anchylostoma. auchylostoma and thread-worms, and the dysentery case had 4 auchylostoma and thread-worms,
All the 15 kala-azar cases were typical of the and the complications were more or less marked. Iu all of them emaciation was a leading symptom; 11 had no anaemia, 3 had it well marked, and one had it slightly so. The spleen was much eularged in 14 cases, and slightly so in the remaining one. There was no dropsy ot auy kind iu 10 of the cases, but it was present iu the five remaining cases in the feet and face; 13 of the 15 cases had a distinct fever history, and iu 11 of them it was recorded by the^ thermometer.
disease,
The
the Goalpara cases admitted into for other diseases except kala-azar, had the symptoms usually met with under their several diseases. The 2 beri-beri cases, it will be noticed, both had anaemia, but were not emaciated, and one of them had slight fever. Tliey had 31 and 8 anchylostoma respectively. One diarrhoea case had slight fever, extreme emaciation, but no oedema, aud had 5 anchylostoma; the second diarrhoea case had slight anaemia, and oedema of face and feet, and 22 anchylostoma. The dysentery case had slight anaemia, general dropsy, 4 anchylostoma, threadOne of the ague worms, and 1 rouud worm. cases was taken ill en route from Pubua, in Bengal to Goalpara, and had 8 anchylostoma. Among the 30 indoor patients admitted into the Dhubri dispensary between December 1892, and February 1893, 19 had the anchylostoma; six had other parasites; and five had no parasites at all. The following are the details:? 19
dispensary
Dysentery, chancre, synovitis, caries of bone, and contused wound were the five cases with no parasites of auy kind. Five others had round worms alone, viz., one remittent fever with diarrhoea; two with malarial cachexia; oue with dropsy of feet, legs and upper limbs; and one with dislocation of the shoulder, and these worms were present in the following numbers 2, 5, 5, 1, aud 1. Another a case of malarial cachexia in a boy aged 12 years, who belonged to Gauhati, but who had lived for three years within six miles of Dhubri had 10 large and 42 small flukes. Thread-worms, with one anchylostoma, existed in a kala-azar case. Ten cases had the anchylostoma by itself aud in the following numbers: 2 beri-beri with 3 aud 4 anchylostoma in each; a kala-az ar case had the ova of the anchylostoma; one a buminuria with ascites had 12 anchylostoma; one dysentery case had 2 anchylostoma. Three malarial fever cases had each 1, 50, and 5 anchylostoma respectively; one debility had 11 anchylostoma; one malarial cachexia had 105
anchylostoma.
34
266
The
INDIAN MEDICAL GAZETTE.
following eight
with rouud
cases
had
anchylostoma
worms; one diarrhoea had 22 anchylostoma and 2 round worms. Three dysentery
had 5, 4, and 7 anchylostoma coupled with 6, 12 and 4 round worms; oue ague had 24 anchylostoma and 9 rouud worms; one beri-beri had 5 anchylostoma and 4 round worms; one malarial fever had 22 anchylostoma and 3 rouud worms; aud oue case, with urinary fistula?, had 11 auchylostoma aud 3 round worms. Iu 16 of the Dhubri dispensary cases, santouiue and castor oil was given on the morning following that on which thymol was giveu; in 12 of these cases no more parasites were obtained, but iu two dysentery cases which gave only 2 auchylostoma in one, and 7 anchylostoma with one round worm in the other: the sautonine and oil uext day brought away 12 rouud worms with 2 auchylostoma and in the second case, 3 round worms only. In an ague case, which originally gave 12 anchylostoma, the santouiue aud oil accounted for 12 more auchylostoma aud 9 rouud worms ; and the fourth case that of urinary fistulae, which originally gave, 11 anchylostoma and 1 round worm, the sautouiue and oil accounted for 2 more round It is possible the parasites, removed by worms. the castor oil aud sautonine, were really on their way out as a result of the previous day's
thymol.
The two kala-azar cases had no anEemia, but had greatly enlarged spleens, one had oedema of feet, but the other had no signs of dropsy. The two beri-beri cases had ausemia but no enlargement of spleen. I admit we see a certain number of cases of intense anannia, at times coupled with dropsy which may be general or partial and, which we unhesitatingly say, is beri-beri, or the "antenna of coolies," but a reference to the tabular statement attached will show that though the anchylostoma may be found in these cases, we find the parasites as frequently and iu quite as great uumbers in others who are absolutely healthy, or have enlarged spleens, or are suffering from diseases with which we know the auchylostoma can have no possible connection, and further, we have the fact demonstrated beyond doubt of its extensive, I might almost add its universal, prevalence all over India as shown in tlie tabular statement followiug, which gives names of the districts aud provinces from which immigrants have come, and iu whom the anchylostoma were The immigrants coming into Assam found. prove this. They are all persous who come from their homes straight into Dhubri after a jouruey of two or three days only, and they are The here submitted to the thymol treatment. Dhubri the of district indigenous population the parasite equally prevalent seem to have among them, and the cases from Pubua, Backerto iu this gunge, aud Cooch Behar referred
report
clearly
[Aug. show the
1893.
exists in the I further think
parasite
districts.
neighbouring Bengal the theory put forth that the Cacharies, Kabhas, Garos, &c., have contracted the disease because of their going in search of work on tea-gardens for some months in the year, where they mix with the imported tea-garden coolies is certainly
far as the inhabitants of the kalaof the Dhubri district are conI am not aware that these people seek cerned. work at all on tea-gardens in Upper and Central Assam. My inquiries, I contend, justify the belief that it has yet to be proved that the anchylostoma is the cause of the kala-azar of this district. Even in cases of so-called beri-beri, is the presence of the anchylostoma in them, convincing evidence that they alone cause the disease and in the way suggested. I think not ! The trichocephalus dispar is evidently not common among immigrants on their arrival in this district in Assam. My previous notes showed this parasite, and the round worm to be very common among the dispensary patients in the Gauhati dispensary. The coolies rejected by me for anaemia, I should consider typical cases of beri-beri. I find my medical subordinates consider " beri-beri to be aniemia without any other complication except the anchylostoma, even though one parasite is found. Kala-azar to be enlarged spleen with no anaemia, malarial cachexia to be an enlarged spleen with anaemia," and with the result of our recent investigations before us, I cannot see that they are altogether The vital statistics for Dhubri district wrong. for 1892 show anchylostoma divided into two heads, kala-azar and beri-beri, and 792 and 14 deaths respectively are shown under each subHow this diagnosis has been arrived at head. the by village chowkidars, I am at a loss to understand? The articles on beri-beri and endemic malarial fevers in Chevers's diseases of At page India are worthy of close attention. 67 he refers to an epidemic of beri-beri fever in 1880 at Dacca, Sylhet, and at Shillong, the head-quarters of the Assam Government, Circular No. 32-S of 26th October 1888, from Dr. Lethbridge, Inspector-General of Jails,
not
proved,
azar
Bengal,
may
so
portions
to
Superintendents, subsidiary jails,
be of interest in connection
inquiry.
I need
scarcely
add
that the
with
this
investigations
embodied in this report have occupied a very considerable amount of time and labour, and in
carrying them out, I have been careful to see that everything herein recorded is absolute fact. Whether the anchylostoma produce beri-beri or kala-azar which diseases are considered by Surgeon-Major Giles to be one and the same disease, is, I think, a question still to be settled. If Surgeon-Major Giles is right, then the inter esting point is at what stage aud when does the
Aug.
1893.]
VAUGHAN ON A CASE OF SNAKE-BITE.
; for I have shown how in 'kala-azar' cases it is often not found, and when found, exists frequently in very small numbers ; in true beri-beri, it is very often found in trifling numbers, and again in absolutely healthy persons it is found in great numbers. I have had no opportunities for making any post-mortem examinations since the investigations embodied in these notes were It is rumoured a begun. German Professor will proceed to the districts where kala-azar is prevalent, in order to make observations on the disease. I trust the statement will prove correct and help to clear up the question. I might add that I have sent half the anchylostoma and flukes found by me to the Principal of the Calcutta Medical College for acceptance on behalf of the College Museum.
parasite become injurious
267
