Is it
AJSTCHYLOSTOMA DUODENALE * widespread m India, Assam and (Jeylon, and is harmless or a harmful parasite ?
it
a
By Hayman Thornhill, m.b., Officer, North Western and Sabaragamuroa
Senior Medical 1*
Provinces, Ceylon.
EXTRACTS FROM THE WORK OF LUTSZ. Translated by Dr. J. D. Macdonald, In Ceylon Medical Journal of April 1890. (Continued from page 384.)
}
Transference to the Human Body.?Apart from the hundreds of accidental circumstances which may carry the larva into the human intestines, there are two principal modes in which it can be effected. In the first place, accumulations of faeces containing ova, over moist, somewhat uneven ground, favouring the accumulation of water here and there, soon lead to profuse development of larvse. These favourable circumstances are found whenever latrines are absent. The excrementa lie scattered in large masses near human dwellings, especially in swampy soil frequently trampled on by men and animals, without any outflow of water. This is the peculiar home of the worm. These conditions are often to be met with in Brazil and other countries where cultivation is in a backward condition and where men and domestic animals are often crowded together within narrow limits.f In the outskirts of small country towns, these conditions are also to be met with, but to a smaller extent, as here latrines, although of a primitive form, are met with ; conditions of this kind are still less seldom met with in large towns. On the other hand, the same results always occur whenever any temporary activity induce the more or less prolonged accumulation of men upon any soil favourable for the development of the worm, as in mining operations and brick-fields. Under such conditions where almost all the larvas develop, the number found over a small area may be enormous, not even to be counted by millions. It is easy to understand how the inhabitants of such localities, in their various habits of life, either from the soil itself or from soiled vessels or clothing, or from portions of the body, especially when they go about, barefooted, may easily, by means of fingers or nails, introduce a number of the encapsuled larvte into their stomachs. This happens especially in the case of work people who take their meals on the spot, and carry their food to their mouths with soiled fingers. On the other hand, infection takes place in the case of young children, still scarcely able to walk as they often crawl on hands and feet, and carry their hands often in a soiled condition to their mouths. Whoever critically examines the fasces of Brazilian children, who, under the favourable influences of climate, play in the open air, clothed only with a small rag of a shirt, will easily understand why a parasite, the stages of development of which are undergone in the soil, especially effect this early age % Read at the Indian Medical Congress, December 1894. t Conditions which are very common in Ceylon. t This also explains why children in Ceylon are so often infected with .the parasite.?J. D. M.. *
A great portion of the larvaa do not, however, develop.in/ the place where the eggs are originally deposited. Immediately after emerging from the shells they commence to wander, and favoured with such downpours of rain, as occur in the tropics, pass over long tracts of soil. Consequences op the presence op the Parasite to the Host.?From what I have said of the mode of living of the adult worm, it will be seen that the invasion of the human organism by a large number of these must be of serious import. As a matter of fact, it has been established by careful observations that the presence of about jive hundred anchylostoma produces severe disturbances even in the strongest adult, and that if the individual be unfavourably placed as to diet, health, $c., a much smaller number luill do the same. These disorders which in common with Grassi and C. Parona, I have included under the term anchylostomiasis are of various kinds, but the most prominent and the most striking is the anaemia caused by them. The ansemia produced may be extreme, and is often recognised by the laity themselves on that account, aa well as on account of its frequency in certain localities.* The coincidence of chlorosis and of an invasion of anchylostoma has been too often established to raise the question of the connection now, even if it appeared to us much less explicable than it really is. The idea that the worms are not the cause, but the consequence of the disease, seems, after all our pathological experiences, rather an unintelligible anachronism. To retain such an idea, knowing what we do of its mode of development, its mode of infection, and its mode of living, would be something strange. I may therefore in this place omit the proof that the disease described by me as anchylostomiasis is entirely due to the presence of the parasite
anchylostoma, *
as
this will become evident further
on.
'EXTRACTS FROM THE WORK OF LEICHENSTERN". Translated by Dr. D. J. Macdonald,
Ceylon Medical Journal of October 1891. re-opening of the numerous brickfields in the neighbourhood of Cologne in March, we resumed our investigations of the occurrence of anchylostoma already known to you. In a small publication of March last, I pointed out that this disease was far from being a rare disease among the brickmakers here, but, on the contrary, At that time I could only report 11 was widely spread. Cases of anchylostomiasis, of which 5 at the time of publication were still in hospital. Since then, i.e., during the last four months, 2G new cases In the
On the
were added to these, a number still on the increase, and from my observations on the brickfields themselves, will bo * further increased three or four-fold. This rapid increase of our material for observation is founded on an undoubted increase of anchylostomiasis on these brickfields, but still more on the fact that we transferred our labour to the brickfields themselves, and contrary to our former practice, sought for and inspected the workers, and examined the stools of suspicious cases for the ova of anchylostoma. The investigations, which have hitherto only extended to a portion of the numerous brickfields in the neighbourhood of Cologne, shew that the assertion made by me in my last publication " that the most, if not all the brickfields are infected " is fully justified. I firmly believe that anchylostomiasis is much more, widely spread among the workers than I had reason to believe a short time ago from my observations. On my former visits I directed my attention only to those who were anaamic in a more or less degree, and in such cases I never failed in my diagnosis. There lately entered the hospital two brickmakers, one with croupous pneumonia, the other with typhoid fever, both with ruddy colour of face and mucous membranes, the very opposite condition to anajmia, and yet in the stools of one 1 found a few ova, in the other in great numbers. It is clear both were in the incipient stage of the disease; the one with the few ova being infected only with a few of the worms, and that of not long duration, the other infected with numerous worms, but evidently the infection was of short duration. The history agrees with this supposition in every respect. Both the patients came to the brickfields for the first time in *
The ansemia
produced by the anchylostoma in Ceylon is most
characteristic, and is easily distinguished from that of malaria and other wasting disease. I have never less than from twenty to thirty cases under treatment in my wards in the hospital.?J D. 51.
Nov.
1895.J
THORN HILL ON ANCRYLOSTOMA DUODENALE.
March last. Iu both cases the worms were expelled, after the acute diseases from which they suffered were cured. On the other hand, a few worms, as experience teaches, may cause extreme anajmia in the course of time? six months or more, whilst acute anaemia may occur within a very short time, if large numbers of the larvae are taken up at one time, in consequence of the large quantity of blood lost. The degree of anaimia met with among the brickmakers naturally varies considerably; sometimes the sun-burnt face does not betray the anaemic conditions. In these cases a glance at the conjunctiva or at the mucous membrane of the mouth is sufficient. The highest degree of anaimia are not to be met with on the fields, because in these stages the patients are no longer fit for work, and are mostly bedridden. During my first visit to the brickfields this year, I was informed of a Dutchman, a native of Maestricht. who was laid up seriously ill in the neighbourhood. I visited him at once and found a strongly built but emaciated young man of 25 years, bedridden for the last seven weeks, auasmic to the highest degree. I examined his stools, and found numerI persuaded him with some difficulous anchylostoma ova. ty to enter the hospital in my charge, where, on the 4th April, 169 anchylostoma were expelled. My visits to the brickfields did not escape observation, as the newspapers cook notice of them. One article in particular, unfortunate in its description of anchylostoma, went through numerous German journals, as patients writing to me from South Germauy shewed. This notice, however I was informwas of considerable service in three cases. ed that two sons of a widow with a large family at Herrem, and a young man in Gotzenkirchen, all of whom were formerly brickmakers, were bedridden for a long time, extremely anaemic, and in spite of medical treatment were daily becoming more so ; I had the three patients transferred to the hospital. The anaemic condition of these was #,s great as that seen in great losses of blood, extreme chlorosis or iu pernicious anaemia. In the stools I fouud numerFrom one of them, Fred Dresen. 20 ous anchylostoma ova. 220 worms; from the second, years of age, were expelled Fried Dresen, 15 years of age, 29 ; and from Hamacher, also 15 years of age, 306 in succession. The case of Fried Dresen in particular from whom only a small number of Chese 29 worms were expelled, shew that blood-sucking parasites are capable of causing the highest in one of decree of anaemia in course of time. Whether of the the cases, in spite of the complete expulsion is to be expected, is doubtful, parasites, complete recovery results of the loug continued because in this case, the anaimia on the part of the heart, and further the swollen are present. spleen, pains in the bones, afternoon fever. &c., of this kind I am perfectly certain that (many) patients bedridden who were formerly brickmakers are helplessly " mysterious" both in Belgium and Holland with this severe anaimia of the Ilhine province ; and yet iu these cases the of faeces would disthe minute a of portion examination cover the cause, and one or two doses of the extract of male fern effect a cure. In my intercourse with the work-people, I often learned that one or other of their former comrades could not come this year to the fields, as he lay sick at home iu Belgium or Holland, as the case might be, anaemic suffering from the Maladie de terre. How easily could help be given to these sufferers. A diminution in the number of the red-blood corpuscles to 1J?!$ millions per ccm. was repeatedly discovered. One case examined by me in 1881 according to Vierordt's method, shewed the haemuglobin reduced to onesixth of the normal, poikilo mikro, and leucocytosis of a moderate degree iu met with in chronic cases. On the other haud, I have never as yet in a Bingle case observed the retinal changes met with in other form-? of chronic anaemia, especially frequent in pernicious anaemia. i.e., haemorrhages with a central yellowish spot. The well on the side of the heart, and known anaemic swnptoms the large vessels, the profuse extremely pale urine, the and the trachycardia dyspnoea on moveclay-coloured faices, ment, &c., are symptoms common to ankylostomiasis and other forms of anaemia. The afternoon fever without any local disease, the so-called anaemic fever, I have met with in three cases of severe anaimia amongst brickmakers. In some severe case I detected considerable swelling of the spleen, as well as pain in the bones, especially in the and ankles was seen in two sternum ; oedema of the feet On the other haud, I frequently once. cases, albuminuria
423
detected albumen in the urine after large doses of tbe extract of male fern and thymol. Besides the well-known symptoms of ansemia, the patient complains of impaired appetite, a disagreeable sensation of pressure, fullness (seldom pain) in the epigastrium ; frequently they suffered These slight gastro-intestinal disorders, from diarrhoea. according to my experience, are experienced often at the very commencement of the disease. (Symptoms of Inva-
sion).
With the expulsion of the worms, the cause of the anosmia is removed, but the parasites are not expelled all at once. Nevertheless very often a strikingly quick recovery is ma le in respect of the disorders of digestion, the appetite rapidly improving sometimes even becoming ravenous ; in such cases the body weight increases, and often in the course of a few weeks after the expulsion of the worms the patient, once miserably wasting away, returns to work well and happy. A noticeable example of this is shewn in the case of the brickmaker, J. J. Dister of Liege, who was given up by his doctors, and who after a long and severe wastiug illness, was on the point of death. To-day, three weeks aftsr I expelled 596 worms, he is quite fit for work, and performs his half hour's walk from the fields to Cologne every morning without the least difficulty. And yet what trouble, it cost me to induce this Walloon and
persuasion.-i
promises
enter the hospital. In other cases, especially in the case of old people, and whenever a certain degree of exhaustion has set in in the htematogeaou-* organs, and nnder unfavourable conditions of life and nutrition, recovery is slow, the patients remaining anaemic with diminished capacity for work for many weeks or mouths even after the worms have been comto
pletely expelled.
Patients return to the brickfield quite cured, but they become quickly infected again amongst companions who are already infected, as very few of these workers have responded to my call to come for treatment an 1 have the
parasites expelled.
In this respect an anaemic Dutchman was not so far wrong in saying to me lately, on my asking him to undergo treatment: " Even if we lived 1U0 years we could not get quit of these worms." It would be wrong to suppose that my efforts on the brickfields of Cologne were either valued or acknowledged, or that I was looked on as a welcome guest there. What I was able to do, I did only with great persuasion, even when brilliant cures were effected, and when I believed I had gained the confidence of this or that labourer, mistrust finally gained the upper haud. It was also extremely difficult to convince the labourers of an infected field of the danger to which they were exposed : although they were already infected. Still they felt themselves well and capable for work for a long time ; only very gradually they became paler and weaker, the actual progress being scarcely noticed, and they attributed their growing weakness in the course of the summer to the excesto the sun, &c. sive exertion required of them fully exposed " " or the pallor of their They said, e'est la maladie de terre, " e'est la couleur de terre." to them, face being pointed out A more diligent race, especially the Walloons, than these brickfield labourers does not exist. At early dawn (3-30 A.M ) they are already busy at work, and with only short interruptions they continue to labour till 9 or 9-30 p M. at night. The proposal that one or a few of them should stop work for a day, to come to hospital for treatment was quite sufficient to break off all intercourse with them. Even Dister Senior, already referred to. whose son, a boy of 18 years of age, was extremely anaemic but still able to work, refused to allow him to come for treatment to the civil " hospital, gratis of course, saying definitely, e'est impossible, il doit travailler sans eesse." I was therefore compelled in many cases where ova were discovered in the 8tool8 to treat the patients on the field itself without stopping them from work, from which cause complete success was often impossible for want of sufficient control. Now and again I myself was forced to desist by rough expression, especially on the part of the Dutch, but th .re were a few noble exceptions. The number of parasites in the intestines naturally varies greatly, as I have already pointed out* and does not
always
*
Centralbl. f. Klin. Med. 1885, No. 12, p. 198.
INDIAN MEDICAL GAZETTE.
424
correspond to the degree of anaemia. This is in direct proportion to the number of worms in the intestine (n) and to the length of their sojourn there (t) and in inverse proportion to the power of resistance of the body (r) ; therefore in comparing cases of anjemia with each other the It is to be remembered that one degree of ana3mia may be already infected with a large number of parasites without shewing signs of antetnia (in which ea e t o. or r is very high), further that r, the power of resist nee, which essentially corresponds with the conditions of l^e and nutrition, becomes in the course of the disease smaller and smaller, whilst in, the number of the parasites through new invasions become always larger. =
^*
01
=
LEI CHEN STERN. Translated By Dr. J. D. Macdonald, In Ceylon Medical Journal of January 1892.
hjemorrhagic diarrhoea and the symptoms of anemia begin with the sexual maturity of the animals, on which a frequent change of place occurs. But, as in old cases of anchylostomiasis, highly striking differences occur in The
amount of ecchymoses in the intestine, differences which are quite independent of the number of anchylostoma present, and which are out of all proportion to the latter, it is more than probable that amongst the anchylostoma in general a more active locomotion takes place only at certain times (times of copulation.) Should the post-mortem be made about this time, more numerous ecchymoses are found, whilst in other cases only a few are met with sometimes notwithstanding a large number of anchylostoma, and almost exclusively where the
respect of the
parasites
are
firmly seated.
At the "certain times" just mentioned the parasites wander about in the intestines, and this possibly explains another known symptom, of which I only became aware during the last month, viz., that the colicky pains are quite absent for long periods, and only at times become severe ; further that, what I only hitherto observed in two cases, the stools always acquired the liajmorrhagic character at the time of the colicky pains and at their close. I may here reply to a question which my critic asks me. '? It would be of importance to learn whether He writes : Leichenstern is justified in calling these ecchymoses bites?" My reply is : What else should they be 1 The diagnosis is quite as simple as that of flea-bites on the skin. Schulthess would have omitted asking these idle questions, if he knew he literature of the subject, and the unanimity of all observers in this respect; and if he himself, which would hare been of the greatest importance to him, had had an opportunity of making a post-mortem examination of a case of anchylostomiasis, he would then have been convinced that ecchymoses only occur ii places where the anchylost ma sit, as Bilharz has so correctly shewn. I am convinced that from the position and grouping alone he would have concluded that the ecchymoses* were bit s, and he would have been the more convinced when he considered that the intestine in question was highly anaamic. and the individual shewed no signs of the hsemorrhigic diathesis, no ecchymoses of the pleura, pericardium, &c. Wh'it else should these ecchymoses therefore be than the bites of the anchylostoma at the place where they are usually met with, and especially at the places they have just left ? But, in order to reply to possible future critics who may have an opportunity of examining cases post-mortem, I must accentuate that the number of ecchymoses is not always proportioned to the number of anchylostoma. Numerous ecchymoses are sometimes found with but a few * I have over and over again demonstrated these ecchymoses to my students in the General Hospital, Colombo, and I cannot understand how any one could ever consider them anything else than anchylostoma bites.?J. D. M. Note.?No other writer has entered so fully into the details of this disease and its causation, or devoted more time to it than Dr. Leichenstern. The fact mentioned by him here has been often observed by myself in my hospital practice. Old cases improve with good nourishment and iron tonics, but they never recover completely. This fact was used by some of my opponents in this respect in Ceylon as an objection to my view that the anajmia was caused by the anchylostoma. Children and young adults succumb rapidly to the disease unless help is afforded to them. Before proper treatment was adopted at the suggestion of Mr. Kynsey, the Principal Civil Medical Officer of the colony the mortality of young cases was something most Neither nourishment nor tonics had the least effect. The quantity of blood sometimes found in the faices is very great.?J. D. M.
disheartening!
[Nov.
1895.
anchylostoma, and this for the reason that the parasites, the younger they are, change their place the more frequently, and further that they make frequent changes at the time of copulation. Should the post-mortem occur at such a time, numerous ecchymo e9 are found, and vice versA. The fact which 1 was the first to recognise of the frequent change of position of the anchylostoma at the beginning of the disease, explain a phenomenon used among others by the opponents of anchylostoma anosmia as an objection, viz., that many cases improve quickly or slowly without any drug being used, or without any spor taneous expulsion of the parasites. The patients become once anaemic remain so, but they occasionally recover so far by good nourishment, &c., in proportion as the parasites become more or less sessile, i v., leave their seat less frequently and cause less haemorrhage from bites. A kind of stable stage is developed iu these old eases. The loss of blood caused by the actual requirements of the parasite itself is more or less replaced by nourishment and the activity of th^ blood-forming organs, whilst these factors in the majority of cases are not sufficient to cover the loss at the coinmencemeut of the disease. But even this may occur, a"d a more or less complete cure of the auasmia may follow, notwithstanding the continuous presence of the anchylostoma in t^eir original place. This can only occur when the number of the parasites is small from the very first.
AJSTCHYLOSTOMA DUODENALE * widespread m India, Assam and (Jeylon, and is harmless or a harmful parasite ?
it
a
By Hayman Thornhill, m.b., Officer, North Western and Sabaragamuroa
Senior Medical 1*
Provinces, Ceylon.
EXTRACTS FROM THE WORK OF LUTSZ. Translated by Dr. J. D. Macdonald, In Ceylon Medical Journal of April 1890. (Continued from page 384.)
}
Transference to the Human Body.?Apart from the hundreds of accidental circumstances which may carry the larva into the human intestines, there are two principal modes in which it can be effected. In the first place, accumulations of faeces containing ova, over moist, somewhat uneven ground, favouring the accumulation of water here and there, soon lead to profuse development of larvse. These favourable circumstances are found whenever latrines are absent. The excrementa lie scattered in large masses near human dwellings, especially in swampy soil frequently trampled on by men and animals, without any outflow of water. This is the peculiar home of the worm. These conditions are often to be met with in Brazil and other countries where cultivation is in a backward condition and where men and domestic animals are often crowded together within narrow limits.f In the outskirts of small country towns, these conditions are also to be met with, but to a smaller extent, as here latrines, although of a primitive form, are met with ; conditions of this kind are still less seldom met with in large towns. On the other hand, the same results always occur whenever any temporary activity induce the more or less prolonged accumulation of men upon any soil favourable for the development of the worm, as in mining operations and brick-fields. Under such conditions where almost all the larvas develop, the number found over a small area may be enormous, not even to be counted by millions. It is easy to understand how the inhabitants of such localities, in their various habits of life, either from the soil itself or from soiled vessels or clothing, or from portions of the body, especially when they go about, barefooted, may easily, by means of fingers or nails, introduce a number of the encapsuled larvte into their stomachs. This happens especially in the case of work people who take their meals on the spot, and carry their food to their mouths with soiled fingers. On the other hand, infection takes place in the case of young children, still scarcely able to walk as they often crawl on hands and feet, and carry their hands often in a soiled condition to their mouths. Whoever critically examines the fasces of Brazilian children, who, under the favourable influences of climate, play in the open air, clothed only with a small rag of a shirt, will easily understand why a parasite, the stages of development of which are undergone in the soil, especially effect this early age % Read at the Indian Medical Congress, December 1894. t Conditions which are very common in Ceylon. t This also explains why children in Ceylon are so often infected with .the parasite.?J. D. M.. *
A great portion of the larvaa do not, however, develop.in/ the place where the eggs are originally deposited. Immediately after emerging from the shells they commence to wander, and favoured with such downpours of rain, as occur in the tropics, pass over long tracts of soil. Consequences op the presence op the Parasite to the Host.?From what I have said of the mode of living of the adult worm, it will be seen that the invasion of the human organism by a large number of these must be of serious import. As a matter of fact, it has been established by careful observations that the presence of about jive hundred anchylostoma produces severe disturbances even in the strongest adult, and that if the individual be unfavourably placed as to diet, health, $c., a much smaller number luill do the same. These disorders which in common with Grassi and C. Parona, I have included under the term anchylostomiasis are of various kinds, but the most prominent and the most striking is the anaemia caused by them. The ansemia produced may be extreme, and is often recognised by the laity themselves on that account, aa well as on account of its frequency in certain localities.* The coincidence of chlorosis and of an invasion of anchylostoma has been too often established to raise the question of the connection now, even if it appeared to us much less explicable than it really is. The idea that the worms are not the cause, but the consequence of the disease, seems, after all our pathological experiences, rather an unintelligible anachronism. To retain such an idea, knowing what we do of its mode of development, its mode of infection, and its mode of living, would be something strange. I may therefore in this place omit the proof that the disease described by me as anchylostomiasis is entirely due to the presence of the parasite
anchylostoma, *
as
this will become evident further
on.
'EXTRACTS FROM THE WORK OF LEICHENSTERN". Translated by Dr. D. J. Macdonald,
Ceylon Medical Journal of October 1891. re-opening of the numerous brickfields in the neighbourhood of Cologne in March, we resumed our investigations of the occurrence of anchylostoma already known to you. In a small publication of March last, I pointed out that this disease was far from being a rare disease among the brickmakers here, but, on the contrary, At that time I could only report 11 was widely spread. Cases of anchylostomiasis, of which 5 at the time of publication were still in hospital. Since then, i.e., during the last four months, 2G new cases In the
On the
were added to these, a number still on the increase, and from my observations on the brickfields themselves, will bo * further increased three or four-fold. This rapid increase of our material for observation is founded on an undoubted increase of anchylostomiasis on these brickfields, but still more on the fact that we transferred our labour to the brickfields themselves, and contrary to our former practice, sought for and inspected the workers, and examined the stools of suspicious cases for the ova of anchylostoma. The investigations, which have hitherto only extended to a portion of the numerous brickfields in the neighbourhood of Cologne, shew that the assertion made by me in my last publication " that the most, if not all the brickfields are infected " is fully justified. I firmly believe that anchylostomiasis is much more, widely spread among the workers than I had reason to believe a short time ago from my observations. On my former visits I directed my attention only to those who were anaamic in a more or less degree, and in such cases I never failed in my diagnosis. There lately entered the hospital two brickmakers, one with croupous pneumonia, the other with typhoid fever, both with ruddy colour of face and mucous membranes, the very opposite condition to anajmia, and yet in the stools of one 1 found a few ova, in the other in great numbers. It is clear both were in the incipient stage of the disease; the one with the few ova being infected only with a few of the worms, and that of not long duration, the other infected with numerous worms, but evidently the infection was of short duration. The history agrees with this supposition in every respect. Both the patients came to the brickfields for the first time in *
The ansemia
produced by the anchylostoma in Ceylon is most
characteristic, and is easily distinguished from that of malaria and other wasting disease. I have never less than from twenty to thirty cases under treatment in my wards in the hospital.?J D. 51.
Nov.
1895.J
THORN HILL ON ANCRYLOSTOMA DUODENALE.
March last. Iu both cases the worms were expelled, after the acute diseases from which they suffered were cured. On the other hand, a few worms, as experience teaches, may cause extreme anajmia in the course of time? six months or more, whilst acute anaemia may occur within a very short time, if large numbers of the larvae are taken up at one time, in consequence of the large quantity of blood lost. The degree of anaimia met with among the brickmakers naturally varies considerably; sometimes the sun-burnt face does not betray the anaemic conditions. In these cases a glance at the conjunctiva or at the mucous membrane of the mouth is sufficient. The highest degree of anaimia are not to be met with on the fields, because in these stages the patients are no longer fit for work, and are mostly bedridden. During my first visit to the brickfields this year, I was informed of a Dutchman, a native of Maestricht. who was laid up seriously ill in the neighbourhood. I visited him at once and found a strongly built but emaciated young man of 25 years, bedridden for the last seven weeks, auasmic to the highest degree. I examined his stools, and found numerI persuaded him with some difficulous anchylostoma ova. ty to enter the hospital in my charge, where, on the 4th April, 169 anchylostoma were expelled. My visits to the brickfields did not escape observation, as the newspapers cook notice of them. One article in particular, unfortunate in its description of anchylostoma, went through numerous German journals, as patients writing to me from South Germauy shewed. This notice, however I was informwas of considerable service in three cases. ed that two sons of a widow with a large family at Herrem, and a young man in Gotzenkirchen, all of whom were formerly brickmakers, were bedridden for a long time, extremely anaemic, and in spite of medical treatment were daily becoming more so ; I had the three patients transferred to the hospital. The anaemic condition of these was #,s great as that seen in great losses of blood, extreme chlorosis or iu pernicious anaemia. In the stools I fouud numerFrom one of them, Fred Dresen. 20 ous anchylostoma ova. 220 worms; from the second, years of age, were expelled Fried Dresen, 15 years of age, 29 ; and from Hamacher, also 15 years of age, 306 in succession. The case of Fried Dresen in particular from whom only a small number of Chese 29 worms were expelled, shew that blood-sucking parasites are capable of causing the highest in one of decree of anaemia in course of time. Whether of the the cases, in spite of the complete expulsion is to be expected, is doubtful, parasites, complete recovery results of the loug continued because in this case, the anaimia on the part of the heart, and further the swollen are present. spleen, pains in the bones, afternoon fever. &c., of this kind I am perfectly certain that (many) patients bedridden who were formerly brickmakers are helplessly " mysterious" both in Belgium and Holland with this severe anaimia of the Ilhine province ; and yet iu these cases the of faeces would disthe minute a of portion examination cover the cause, and one or two doses of the extract of male fern effect a cure. In my intercourse with the work-people, I often learned that one or other of their former comrades could not come this year to the fields, as he lay sick at home iu Belgium or Holland, as the case might be, anaemic suffering from the Maladie de terre. How easily could help be given to these sufferers. A diminution in the number of the red-blood corpuscles to 1J?!$ millions per ccm. was repeatedly discovered. One case examined by me in 1881 according to Vierordt's method, shewed the haemuglobin reduced to onesixth of the normal, poikilo mikro, and leucocytosis of a moderate degree iu met with in chronic cases. On the other haud, I have never as yet in a Bingle case observed the retinal changes met with in other form-? of chronic anaemia, especially frequent in pernicious anaemia. i.e., haemorrhages with a central yellowish spot. The well on the side of the heart, and known anaemic swnptoms the large vessels, the profuse extremely pale urine, the and the trachycardia dyspnoea on moveclay-coloured faices, ment, &c., are symptoms common to ankylostomiasis and other forms of anaemia. The afternoon fever without any local disease, the so-called anaemic fever, I have met with in three cases of severe anaimia amongst brickmakers. In some severe case I detected considerable swelling of the spleen, as well as pain in the bones, especially in the and ankles was seen in two sternum ; oedema of the feet On the other haud, I frequently once. cases, albuminuria
423
detected albumen in the urine after large doses of tbe extract of male fern and thymol. Besides the well-known symptoms of ansemia, the patient complains of impaired appetite, a disagreeable sensation of pressure, fullness (seldom pain) in the epigastrium ; frequently they suffered These slight gastro-intestinal disorders, from diarrhoea. according to my experience, are experienced often at the very commencement of the disease. (Symptoms of Inva-
sion).
With the expulsion of the worms, the cause of the anosmia is removed, but the parasites are not expelled all at once. Nevertheless very often a strikingly quick recovery is ma le in respect of the disorders of digestion, the appetite rapidly improving sometimes even becoming ravenous ; in such cases the body weight increases, and often in the course of a few weeks after the expulsion of the worms the patient, once miserably wasting away, returns to work well and happy. A noticeable example of this is shewn in the case of the brickmaker, J. J. Dister of Liege, who was given up by his doctors, and who after a long and severe wastiug illness, was on the point of death. To-day, three weeks aftsr I expelled 596 worms, he is quite fit for work, and performs his half hour's walk from the fields to Cologne every morning without the least difficulty. And yet what trouble, it cost me to induce this Walloon and
persuasion.-i
promises
enter the hospital. In other cases, especially in the case of old people, and whenever a certain degree of exhaustion has set in in the htematogeaou-* organs, and nnder unfavourable conditions of life and nutrition, recovery is slow, the patients remaining anaemic with diminished capacity for work for many weeks or mouths even after the worms have been comto
pletely expelled.
Patients return to the brickfield quite cured, but they become quickly infected again amongst companions who are already infected, as very few of these workers have responded to my call to come for treatment an 1 have the
parasites expelled.
In this respect an anaemic Dutchman was not so far wrong in saying to me lately, on my asking him to undergo treatment: " Even if we lived 1U0 years we could not get quit of these worms." It would be wrong to suppose that my efforts on the brickfields of Cologne were either valued or acknowledged, or that I was looked on as a welcome guest there. What I was able to do, I did only with great persuasion, even when brilliant cures were effected, and when I believed I had gained the confidence of this or that labourer, mistrust finally gained the upper haud. It was also extremely difficult to convince the labourers of an infected field of the danger to which they were exposed : although they were already infected. Still they felt themselves well and capable for work for a long time ; only very gradually they became paler and weaker, the actual progress being scarcely noticed, and they attributed their growing weakness in the course of the summer to the excesto the sun, &c. sive exertion required of them fully exposed " " or the pallor of their They said, e'est la maladie de terre, " e'est la couleur de terre." to them, face being pointed out A more diligent race, especially the Walloons, than these brickfield labourers does not exist. At early dawn (3-30 A.M ) they are already busy at work, and with only short interruptions they continue to labour till 9 or 9-30 p M. at night. The proposal that one or a few of them should stop work for a day, to come to hospital for treatment was quite sufficient to break off all intercourse with them. Even Dister Senior, already referred to. whose son, a boy of 18 years of age, was extremely anaemic but still able to work, refused to allow him to come for treatment to the civil " hospital, gratis of course, saying definitely, e'est impossible, il doit travailler sans eesse." I was therefore compelled in many cases where ova were discovered in the 8tool8 to treat the patients on the field itself without stopping them from work, from which cause complete success was often impossible for want of sufficient control. Now and again I myself was forced to desist by rough expression, especially on the part of the Dutch, but th .re were a few noble exceptions. The number of parasites in the intestines naturally varies greatly, as I have already pointed out* and does not
always
*
Centralbl. f. Klin. Med. 1885, No. 12, p. 198.
INDIAN MEDICAL GAZETTE.
424
correspond to the degree of anaemia. This is in direct proportion to the number of worms in the intestine (n) and to the length of their sojourn there (t) and in inverse proportion to the power of resistance of the body (r) ; therefore in comparing cases of anjemia with each other the It is to be remembered that one degree of ana3mia may be already infected with a large number of parasites without shewing signs of antetnia (in which ea e t o. or r is very high), further that r, the power of resist nee, which essentially corresponds with the conditions of l^e and nutrition, becomes in the course of the disease smaller and smaller, whilst in, the number of the parasites through new invasions become always larger. =
^*
01
=
LEI CHEN STERN. Translated By Dr. J. D. Macdonald, In Ceylon Medical Journal of January 1892.
hjemorrhagic diarrhoea and the symptoms of anemia begin with the sexual maturity of the animals, on which a frequent change of place occurs. But, as in old cases of anchylostomiasis, highly striking differences occur in The
amount of ecchymoses in the intestine, differences which are quite independent of the number of anchylostoma present, and which are out of all proportion to the latter, it is more than probable that amongst the anchylostoma in general a more active locomotion takes place only at certain times (times of copulation.) Should the post-mortem be made about this time, more numerous ecchymoses are found, whilst in other cases only a few are met with sometimes notwithstanding a large number of anchylostoma, and almost exclusively where the
respect of the
parasites
are
firmly seated.
At the "certain times" just mentioned the parasites wander about in the intestines, and this possibly explains another known symptom, of which I only became aware during the last month, viz., that the colicky pains are quite absent for long periods, and only at times become severe ; further that, what I only hitherto observed in two cases, the stools always acquired the liajmorrhagic character at the time of the colicky pains and at their close. I may here reply to a question which my critic asks me. '? It would be of importance to learn whether He writes : Leichenstern is justified in calling these ecchymoses bites?" My reply is : What else should they be 1 The diagnosis is quite as simple as that of flea-bites on the skin. Schulthess would have omitted asking these idle questions, if he knew he literature of the subject, and the unanimity of all observers in this respect; and if he himself, which would hare been of the greatest importance to him, had had an opportunity of making a post-mortem examination of a case of anchylostomiasis, he would then have been convinced that ecchymoses only occur ii places where the anchylost ma sit, as Bilharz has so correctly shewn. I am convinced that from the position and grouping alone he would have concluded that the ecchymoses* were bit s, and he would have been the more convinced when he considered that the intestine in question was highly anaamic. and the individual shewed no signs of the hsemorrhigic diathesis, no ecchymoses of the pleura, pericardium, &c. Wh'it else should these ecchymoses therefore be than the bites of the anchylostoma at the place where they are usually met with, and especially at the places they have just left ? But, in order to reply to possible future critics who may have an opportunity of examining cases post-mortem, I must accentuate that the number of ecchymoses is not always proportioned to the number of anchylostoma. Numerous ecchymoses are sometimes found with but a few * I have over and over again demonstrated these ecchymoses to my students in the General Hospital, Colombo, and I cannot understand how any one could ever consider them anything else than anchylostoma bites.?J. D. M. Note.?No other writer has entered so fully into the details of this disease and its causation, or devoted more time to it than Dr. Leichenstern. The fact mentioned by him here has been often observed by myself in my hospital practice. Old cases improve with good nourishment and iron tonics, but they never recover completely. This fact was used by some of my opponents in this respect in Ceylon as an objection to my view that the anajmia was caused by the anchylostoma. Children and young adults succumb rapidly to the disease unless help is afforded to them. Before proper treatment was adopted at the suggestion of Mr. Kynsey, the Principal Civil Medical Officer of the colony the mortality of young cases was something most Neither nourishment nor tonics had the least effect. The quantity of blood sometimes found in the faices is very great.?J. D. M.
disheartening!
[Nov.
1895.
anchylostoma, and this for the reason that the parasites, the younger they are, change their place the more frequently, and further that they make frequent changes at the time of copulation. Should the post-mortem occur at such a time, numerous ecchymo e9 are found, and vice versA. The fact which 1 was the first to recognise of the frequent change of position of the anchylostoma at the beginning of the disease, explain a phenomenon used among others by the opponents of anchylostoma anosmia as an objection, viz., that many cases improve quickly or slowly without any drug being used, or without any spor taneous expulsion of the parasites. The patients become once anaemic remain so, but they occasionally recover so far by good nourishment, &c., in proportion as the parasites become more or less sessile, i v., leave their seat less frequently and cause less haemorrhage from bites. A kind of stable stage is developed iu these old eases. The loss of blood caused by the actual requirements of the parasite itself is more or less replaced by nourishment and the activity of th^ blood-forming organs, whilst these factors in the majority of cases are not sufficient to cover the loss at the coinmencemeut of the disease. But even this may occur, a"d a more or less complete cure of the auasmia may follow, notwithstanding the continuous presence of the anchylostoma in t^eir original place. This can only occur when the number of the parasites is small from the very first.
