320 THE INDIAN MEDICAL GAZETTE [June, 1935

THE PASSAGE OF HOOKWORMS AFTER TREATMENT

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

and

A. K. MUKERJI, m.b.

(From the Helminthological Research Laboratory, Endoument Fund, School of Tropical Medicine,

Calcutta)

In industrial practice the impossibility of

keeping under control large numbers of coolies for a prolonged period after mass treatment for hookworm infection has led to the employment of various rough and ready methods of assessing the efficacy of such treatment. One of the commonest of these is to examine for the

presence of hookworms the first stool passed after treatment. The senior author has several times been asked what he considered to be the value of this method, and while expressing the opinion it was probably not of much use he

always had the feeling/ he might be wrong, because as far as he knew no definite data on the point were available. It was accordingly decided to investigate this question. The following method was adopted in the

inquiry. Only hospital in-patients were made use of because sufficient supervision of out-

patients was impracticable. All the patients were treated by our usual routine method; they were given 3 c.cm. of tetrachlorethylene and 1 c.cm. of oil of chenopodium shaken up in two ounces of saturated solution of magnesium sulphate. The treatment was given at 6 a.m. and from this hour until 6 p.m. on the same

day all the stools passed were kept separate and individually examined for hookworms by washing through a fine sieve, the times at which all the stools in this first twelve hours were

passed was also noted. From 6 p.m. until 6 a.m. the following morning any stools passed were examined for each patient as a whole and

the same was done for the second, third and fourth twenty-four-hour periods respectively. One hundred cases treated for hookworm

infection in the Carmichael Hospital for

Tropical Diseases were dealt with in the above manner. Many of these were only light infec- tions as they had been admitted for conditions other than hookworm infection and the latter was only found in the course of the usual routine examinations. It was noticed that the

proportion of lightly infected persons failing to pass worms in the first stool was slightly higher than that of those more heavily infected; this

point is discussed below.

Seventy-three patients were cured, but as

cure or failure to cure had no bearing at all on the passage of worms in the first stool this

aspect has been ignored and cured and uncured cases are discussed together. Cure was con-

sidered established if the patient showed no eggs in a direct centrifugal flotation preparation ten days after treatment. Egg counts were done on all the patients before treatment with the idea of gaining an approximate estimate of the number of worms that might be anticipated from each case, but as they showed absolutely no correlation with the number of worms sub- sequently passed they have not been considered.

Altogether 42 of the patients passed no worms in the first stool and 22 passed the first stool between 6 and 6-30 a.m., that is within half an hour of the treatment being given, and eight of these 22 passed worms in the stool. Of the 14 who did not pass worms in the first stool 5

passed their stools between 6 and 6-15 so it is

considered better not to include these 5 as

failures to pass worms, as it was such a short time after treatment, therefore of this group we can say that 8 passed worms and 9 failed to do so. As a check on the time that worms might be expected to appear in the stools after treat- ment those passing their first stool between 6-30 and 8 a.m. were taken separately; there

were 26 in this group and 13 passed worms while 13 did not do so. A further check was

the taking of those who passed their first stools between 8 and 10 a.m., there were 25 in this

group and only 10 of them passed worms in the first stool. From these observations it seems

safe to assume that the chance of finding worms in stools passed half an hour after treatment- is as good as when the stool is retained far

over two hours. Therefore, excluding the 5 who

passed stools earlier than 6-20 a.m., we can say that 39 persons failed to pass worms in the

first stool, and 27 of these passed less than a

total of 20 worms.

It was mentioned above that the proportion of failures to pass worms in the first stool was somewhat greater among the light infections, so a division was made between those passing 1 to 19 worms and those passing 20 or more- Out of 55 lightly infected 28 passed worms an^ 27 did not (this indudes 3 who passed stools

June, 1935] HYDRONEPHROSIS : MAHADEVAN & MENON 221

infp r anc* ^ie 45 with heavier fin i TS o

Passed worms and 15 did not

a rn\ tS 2 who passed a stool before 6-20

numlo # heavy infection group the

r i ,.

ers ?f wpnns passed in the first stool in

m +i10n<- Ti ? total number passed are shown

ie following list, the left hand figure being number in the first stool and the right hand ?f9e7 Jhe total :?0|48, 2/32, 15/27, 1 92, oEVJ ^o 7, 80'84' 8J29> 7i77> 10l41> 60 67> ? 748| 1,249, 92)109, 0|28, 22|27, 32 34, n qi fcSSed ,at 6'10)' 164/199, 219/233, 0/360, 4011 no 'io?i 1'21' ?'27' ?122> ?l20' ?'29> 031> 17q2 'J I66' 182l199> 0/23, 0/157, 0/39, 30,70, 651^902 "I200' ?I1I2> 18l124; 15l35> 49 94-

*s. usual for us to give a second dose of

h,Jnesir sulphate at 10 a.m. if the bowels jn .e 110 a^ted by that time and in the present

^e cases had to be given this

tin * and ^ was found that the propor-

m^-i Yi?rms. Passed in the first stool was siderably higher than the average of the cases shown above, and also 14 of the 16

ssed worms in the first stool. Some of the gures in the following list have already been

^ 7,en,JI? ^ne one above and to these have been '

c, the ones who passed less than 20 worms, I;

, a sec?nd dose of purgative:?49/102,

ooi^o'J*19'233> 0/2, 11(11, 13/19, 164 199, 7/77, '

Alt? ' T0'16, 3'6' 2i2> 32l34> 3I3> 910> ?IL l ?

i nough the proportion here is distinctly ]g ier than in the above group it still shows fj lat even after a long delay and the adminis- ! a ion of a second dose of purgative by no

'

leans all the worms are passed in the first o 00J ,,

be also noted that in this group ot tiie patients passed all the worms in the

rst stool and were cured, but they only pro- uced 11, 3 and 2 worms respectively. Two ler cases were cured that passed all their

7-1^ *n stool, one passing 7 worms at ~

a-m-, and the other 1 worm at 10 a.m. ?

together 62 patients passed worms on the 0n

^ay, and 9 of these had passed no worms tiie first day although they all had one or .

infr<VS^?0^S ?n ^la^ daY- These 9 were all light ections with the exception of one, and this

?j ilad two stools on the first day and passed

on fi?V01i?S on ^le second day, followed by 5

ino- *"ird. This shows that a delay in pass-

g worms for over 24 hours does not ensure

wle Passage of all in one stool. Another case

hv sfe"a^ comment is one that passed o stools on the first day with no worms in the rst stool and 98 in the second which was passed

on P-1"'' tilis was followed by 243 worms " the second day and 16 on the third day.

xi. ^enty-two patients passed worms on the nird day, and in two of these this was the first ccasion on which worms were found, but only Worms were passed in one case and 1 in the ner. Out of 20 patients whose stools were

(Continued at foot of next column)

{Continued from previous column)

examined on the fourth day 2 passed one worm each and one passed 3 worms.

Disintegration of worms that have been killed by an anthelmintic is fairly rapid in the intestine so it is probable that many more worms were passed than could be recognized as such, especially on the second, third and fourth days. Against this fact it might be advanced that as worms were found on these three days disintegration cannot have been very rapid. The probable explanation of this is that we have found (contrary to the usual opinion) that the majority of worms evacuated as a

result of tetrachlorethylene and oil of cheno-

podium treatment- are alive and can be seen

moving when placed in water.. Although not

dead their movements are very feeble compared with worms obtained without treatment as in the course of at post-mortem examination, so

what probably happens is that the worms are

sufficiently intoxicated by the drugs to make them loose their hold on the gut and not being able to regain its they are swept out in the faces. The recognizable worms that were found on the second, third and fourth days are prob- ably worms of this class, that have been loosened from the gut but not killed. As is usual with any series of hookworm

infections examined in Bengal the majority of these persons had mixed infections with Ancy- lostoma duodenale and Necator americanus with a marked predominance of the latter species, and a careful analysis of our results from the point of view of the influence of the species on the time of evacuation showed that there was no correlation between these two factors.

? Conclusion

The above observations clearly demonstrate that after an efficient anthelmintic treatment the examination of the first stool only, after treatment, gives no indication of the number of worms harboured by the patient, nor of how

many cases can be regarded as cured.