HOOKWORM AND MALARIA RESEARCH IN MALAYA, JAVA, AND THE FIJI ISLANDS HOOKWORM AND MALARIA RESEARCH IN MALAYA, JAVA, AND THE FIJI ISLANDS REPORT OF UNCINARIASIS COMMISSION TO THE ORIENT 1915-1917 S. T. DARLING, M.D. M. A. BARBER, PILD. H. P. HACKER, M.D. PUBLICATION NO. 9 THE ROCKEFELLER FOUNDATION INTERNATIONAL HEALTH BOARD NEW YORK CITY 1920 INTERNATIONAL HEALTH BOARD OFFICERS AND MEMBERS GEORGE E. VINCENT, Chairman WICKLIFFE ROSE, General Director HERMANN M. BIGGS WALLACE BUTTRICK SIMON FLEXNER FREDERICK T. GATES WILLIAM C. GORGAS (Deceased) EDWIN 0. JORDAN STARR J. MURPHY JOHN D. ROCKEFELLER, JR. WILLIAM T. SEDGWICK VICTOR C. VAUGHAN WILLIAM H. WELCH EDWIN R. EMBREE, Secretary ADMINISTRATIVE STA FF WICKLIFFE ROSE, General Director JOHN A. FERRELL, M.D., Director for the United States VICTOR G. HEISER, M.D., Director for the East HECTOR H. HOWARD, M.D., Director for the West Indies L. W. HACKETT, M.D., Associate Regional Director (for Brazil) ERNST C. MEYER, PH.D., Director of Surveys and Exhibits 5(m3'I9 Lung , AUTHORS’ NOTE This volume represents an abridgment of the detailed report sub- mitted by the undersigned as a result of their inquiries into the extent and importance of hookworm disease in Malaya, Java, and Fiji, and the comparative significance of this disease and malaria as disabling factors. Mr. Robert Goldsmith assisted in rewriting and condensing the voluminous data which comprised our original manuscript and arranged them in their present convenient form. The unabridged report is being preserved intact in the library of the Rockefeller Foundation, where persons who are interested may consult it. 2. Our work was intended to make no effort toward the control of either hookworm disease or malaria. Its purpose was merely in- vestigative. The authors regret that in many cases they found it impossible to secure a satisfactory number of cases for their experi- ments. This difficulty applied particularly in the case of their studies of various drugs for use in treating hookworm disease. Many patients absconded during the rather prolonged periods it was necessary to keep them under observation and treatment. The reader will recognize the experiments in which the number of cases considered was perhaps too small for satisfactory conclusions to be drawn from them, and will understand that the results of the ex- periments are to be taken not as suflicient in themselves to establish facts, but as subject to confirmation by more extended investigation. To this end the number of cases considered in each experiment has been clearly indicated in each of our various tables and graphs. 3. It should be understood, further, that many of the experiments, more particularly those relating to the treatment of hookworm disease, were carried out in jails and hospitals. It may be that under less perfectly controlled conditions, such as those which obtain in the field, certain differences would have resulted in the findings, which in turn would have required certain modifications in our recommendations. 4. The authors desire to acknowledge their indebtedness to the medical and administrative officers of the countries visited, to the planters, and to the other officials and private citizens who placed their time and facilities so generously and unreservedly at the dis- posal of the Commission. Especial thanks are due Sir Arthur H. Young, K.C.M.G., Governor of the Straits Settlements and High Commissioner of the Federated Malay States; Sir Edward L. Brock- man, K.C.M.G., Chief Secretary of the Federated Malay States; Dr. Charles Lane Sansom, C.M.G., Principal Medical Officer of the Federated Malay States; Dr. W. Gilmore Ellis, P.C.M.O., Straits Settlements; Dr. W. Th. deVogel, Hoofd Inspecteur Geneeskundigen Deinst in Nederlandsch Indie; and Dr. G. W. A. Lynch, P.M.O., ix x AUTHORS’ NOTE Fiji, for the invaluable opportunities for investigation which they accorded the Commission. 5. A tabular summary of the findings of the Commission follows the regular text matter of the report. This summary consists of fifty-five separate tables, pages 120 to 178. The more important facts presented in the tables have been arranged in graphic form, and the graphs have been placed as close as possible to the text which discusses the facts they exhibit. There is a separate graph for practically every table. The text matter, in addition to being accompanied by the graphs which relate to it, contains reference to the supporting tables, and the graphs and tables in their turn have been given proper cross references. This system will aid the reader to locate at once all facts bearing on any particular subject, whether the facts be in graphic, text, or tabular form. 5. T. DARLING M. A. BARBER H. P. HACKER CONTENTS CHAPTER PAGE I POPULATION AND LIVING CONDITIONS .................. 1 II ORIGIN or THE INVESTIGATION ..................... 12 III EXTENTOFTHE INVESTIGATION....................... 16 IV METHODSOF EXAMINATION........................... 22 V METHODSOFTREATMENT............................. 32 VI FINDINGS CONCERNING HOOKWORM INFECTION. . . .. .. .. . 47 VII FINDINGS CONCERNING MALARIA ................... . . . 65 VIII FINDINGS CONCERNING ANEMIA.....‘.................. 83 TABULAR SUMMARY .................................. 118 xi ILLUSTRATIONS PAGE MapofFederated MalayStates. .. .. ...........Facing 1 Map of Java ................................................ 6 Men and womenasbeastsofburden. 9 ThehillsawahsofJava...................................... 9 Oneofthecanalsofold Batavia,Java......................... 10 Foodbeingsoldfromthe ground 10 Laboratory of Uncinariasis Commission to the Orient, Kuala Lum- pur, Federated MalayStates..... .. .. .. 13 Interior of field laboratory, used by the Commission in Java. . . . . . . 13 SceneinBatavia.....................i.....4................ 14 Group of night-soil coolies in the Federated Malay States ........ l7 Malay boys’ school, Kampong Bharu, Kuala Lumpur. . .. .. . .. .. . 18 Night-soildisposal.....r.V........................... ..23,24 PrisonersinJavajail............... 29 Dr. Darling making the hookworm survey in Batavia jail ......... 29 SquadNo.3,Javajail..................r.................... 30 SquadNo.2,Javajail.............. 30 Hookworm patient, just before being discharged from Kuala Lum- purhopsital.............................................. 43 Severe case of hookworm anemia in Chinese youth .............. 44, 45 Group of former residents of Federated Malay States and Straits Settlements examined at St. John’s quarantine camp, Singapore . . 46 Two cases of hookworm anemia in Mid-Java .................... 61 Cases of hookworm anemia and malarial anemia contrasted ....... 62 Estate children .............................................. 71 Treatment squad in Sawah Besar, Batavia ...................... 72 People of Batavia treated at Kampong Kramat ................. 75 Two cases of hookworm infection in the highly malarious kampong ofJaagpad,Java................. 75 A prolific breeding place for the anophelines which spread malaria in Batav1a 76 Types of natives in treatment squad at Tjimatjan, Java .......... 85 A vigorous dessa man carrying his plow on his shoulders to the fields 85 Seven cases of hookworm infection with anemia, from Karangsari and Wmosari 86 Treatment squad, Jaagpad, Batavia ........................... 86 Group of children living on an unhealthful rubber estate in the MalayStates............................................. 97 Tamil children on an estate relatively free from malaria .......... 98 Tamil and Chinese with severe. anemia and waxy pallor .......... 107 Hospital patient just before discharge and after hookworm treat- ment...... 108 Same case four andone-l‘alf months after discharge from hospital. . 108 xiii o o o.- - ooo , o 0.". ' H: ' ' a. o no. . u . .0 n so . co 0 0'. a I O ' o o- b. ' ' a a. ‘O """"" n . on. 0" ' Fig 1.—Map of Federated Malay Stat es CHAPTER I POPULATION AND LIVING CONDITIONS Before the work of the Uncinariasis Commission to the Orient is reviewed in detail, the chief features of the countries visited will be briefly discussed, and some of the characteristics of their people will be mentioned. I. THE FEDERATED MALAY STATES The Malay Peninsula is situated in the most southeasterly portion of Asia and extends from the Isthmus of Kra to Cape Romania, a distance of 750 miles in latitude 1.5° to 6° N. Its width varies from 60 to 200 miles, and the total area of the Peninsula is 70,000 square miles. The area of the Federated Malay States alone is more than 25,000 square miles. Topography of the Country. limestone constitutes the backbone of the Peninsula. in this range reach a height of 8,000 feet. The largest A mountain range of granite and Certain peaks alluvial tin depos- its in the world are situated at the foot of the western slope of these mountains. Thecoastalplains on both sides of the mountain range extend from five to thirty miles; the eastern plain, which reaches to the China Sea, is the wider of the two. CHINESE (433.244) MALAYS (420.340) INDIANS (ITZ, 465) EUROPEANS ( 3.264) EURASIANS (2.643) CLASSIFIED (4. 5m Fig. 2.——Population of Federated l\/1alay States. By race. Census 1911. (Table 1) Many mangrove swamps are to be found on the western coast, which terminates at the Straits of Malacca. Climate of Malaya. The climate of Malaya is tropical but it is less oppressive than that of Panama, for example, because the porosity of the soil prevents the air from acquiring the highest pos- sible degree of saturation. Although the days are hot, the nights are usually cool. There are no prolonged periods of drought or rain, but there are between 150 and 200 rainy days each year, with a total annual rainfall ranging from 75 to 150 inches. I 2 INTERNATIONAL HEALTH BOARD Population of Malaya. The work of the Commission in the Peninsula was confined to the Federated States and the Straits Settlements. The population of these states in 1911, according to census returns, was 1,036,999. (See Tables 1 and 2, pages 120 and 121.) Of this number about 725,000 were males and about 312,000 females, with great disparity of the sexes among the Chinese. All native adult females live either in marriage or in concubinage. It is an interesting fact that nearly four-fifths of all the people dwell in rural districts. With respect to religion, when the last census was taken it was found that of the total population there were about 400,000 Mohammedans, some 136,000 Hindus, approximately 7,000 Sikhs, and about 23,000 Christians. Ancestral worship was practiced by nearly all the Chinese, who numbered more than 350,000. Character of the Native Malay. The native Malay is, as a rule, very superstitious. He believes, for instance, that Hantu, or evil spirits who live in trees, lurk about the house at night and exert a malignant influence on his family, his ani- mals, his crops, and himself. It must not, however, be inferred from this that all Malays are devoid of intelligence. On the contrary, any one who has had experiencein teaching these peo- Fig. 3.—Population increase of pie is enthusiastic about their Federated Malay States, 1901-1911. mental ability. While it is a BY race. (Table 2) common opinion that all Malays are indifierent and indolent, this is not the case except in the Federated States, where the natives' wants are few and where it is possible for them to supply these wants by merely a modicum of labor. In Java, where the popula- tion is more dense and where there is consequently a real struggle for existence, the Malays are both alert and industrious. It is therefore proper to assume, with reference to permanent disease control measures, that both men and women would not be averse to receiving instruction in hygiene. But it is not highly probable that the Malays of the Federated States would be likely to inaugurate, or even to co-operate in bringing about, sanitary reforms which require concentrated and persistent effort. There is great lack of initiative. It may be that intermarriage and concubinage .. :3 ‘74 O") '0‘! L CES CHINESE is I90|CENSUS l9ll CENSUS POPULATION AND LIVING CONDITIONS 3 of Malay women with men of the more virile races—particularly the Chinesefiwill in the course of time have the effect of altering somewhat the present listless character of the native. Character of the Tamil Coolie. Most of the Tamil coolies in the Federated States come from the Madras Presidency in southern India, and are in the main ignorant, superstitious, and servile. Probably not more than 5 per cent of them are able to write their names. While it is true that Tamils are hard workers, it is also true that they are almost entirely lackingin ambition. Docile, unstable, and apparently quite incapable of administering their own affairs with either dispatch or intelligence, they constitute the white man's burden. But for the best interests of society they should not be permitted to exclude themselves from the civilizing influence of edu- cation; in their case there is marked need for instruction along the lines of sanitation. Their diSinCIina' DENSITY PER SQUARE MILE tion, for instance, I00 200 300 400 soo soo 700 to use the latrines provided by the ENGLAND Government or FRANCE by the estates on '90 ' INDIA which they are em- ployed, is a direct menace to the CEI‘QEON communityand, it [:_ is not too much to say, an indirect menace to the world. There is no doubt that the natives carry with them large num- bers of hookworms, and, as a result of insanitary habits, dispense them throughout the communities in which they settle. AUSTRALIA Fig. 4.—Density of population, Federated Malay States, compared with other countries. (Table 3) Character of the Chinese Coolie. The residence of the Chinese coolies in the Federated Malay States is usually transitory. A few may plan to remain permanently, but for the most part it is the intention of these migratory people to work and save for a com- paratively brief period, and then return to China. The materia median of the coolie is medieval. Even hospital attendants have been known to eat dog, really believing it to be an eflicacious remedy for certain prevalent diseases. Such ignorance, however, must not be taken to mean that the coolies are altogether indifferent to the importance of education. The fact is that they are not averse to general instruction with respect to both personal hygiene and sanitary reform. But probably because of their extraor- dinary racial obstinacy it is extremely difficult to convince the coolies, 2 4 INTERNATIONAL HEALTH BOARD by argument, of the urgent need of actually doing their part in effecting such reform. The principal diet of these people is boiled rice with some pork, fowl, or fish, and a number of vegetable and “paste" dishes highly seasoned with chilies. All except Straits-born Chinese use chop- sticks. The Chinese eat more generously than the Tamils. Chinese coolies bear the brunt of the hard work that is done in Malaya. In round numbers, approximately 150,000 are engaged in mining, 65,000 in agricultural pursuits, 10,000 as woodcutters, and 7,000 as rickshaw pullers. Chinese on rubber estates receive higher wages than Tamils. One reason is that they are more efficient workers;‘another is that they sufl'er less from malaria infec- tion, and for that reason are less expensive to keep in good physi- cal condition. Tamils receive from 30 to 40 cents a day, in Straits currency. (One dollar in Straits currency equals about 55 cents in United States money.) Chinese tappers, however, are frequently paid as much as 50 cents a day. Between wages and hemoglobin content there is a marked parallel which is more than a mere coincidence. ,7, In other words, the better — 1" physical stamina of the Chi- INWNS CH'NESE MAI-“5 nese, as contrasted with the - Tamil, means higher wages for Fig. 5,—Population of Federated the former. Ml Sttl'v' tt.B . use?" (12381;)ng on es a CS y Education in Malaya. In 1912 there were 373 vernacular schools in Malaya—one in almost every village. All of these schools were either under direct government control or aided by government grants. There were, in addition, a few Tamil and a few Chinese schools situated where the Tamil and Chinese populations, respec- tively, were particularly numerous. AI) 0 z ‘1 m 3 o I )— Principal Industries of Malaya. The principal industries of Malaya are mining and agriculture. In 1912 a little over 280,000 acres were leased for mining purposes; more than 26,000 acres were actually occupied; the value of the products amounted to more than $84,000,000; and over 160,000 persons were engaged in one or another mining industry, tin ore being the chief mining product. Many alluvial fields are both owned and worked by Chinese. For POPULATION AND LIVING CONDITIONS 5 a considerable period coffee was the principal product raised on 550000 the estates, or plantations, but 500900 - 450.000 in recent years planters have $ - - 400000 u been growmg rubber in prefer- .4 n e ._Dl ence, because it is so much more 350'000 "‘ profitable. Cocoanuts and rice 3°°'°°° o . m are also grown; in the year 1912 250000 3. over 150,000 acres were devoted 2°°'°°° ‘2 9 to theformer. (SeeTables4and '50‘000 Q N a, :3. 5- . _ m m 5, pages 123 and 124.) '°°'°°° £6 5‘ ‘2 “’ M 50000 " 3 «'3 Government of Malaya. -- _ , .3 . . . o I EMM - xx Inasmuch as it IS a fixed policy 8 g 8 R g g :3 .,, g 5 3§ of the Rockefeller Foundation '2 '3 K’ 3- ‘3} 3;. ‘° :- 2 2} 3; .0» . on re .0 N N Ln ‘ so International Health Board al- I g m g k, : m i m S m 5. ways to work in the closest g _. ;_ jg g possible co-operation with the E ‘2 g3 g1: 95 g u u D _‘ _ > Government in the countries 5 g 23 gg E; d . . . u. where It IS laboring, a few words '3 1‘" 3 8g i will be said about the history -MALE -FEMALE and the government of Malaya. , . Since the conclusion of the F1g.6.—Populat10n of Federated - Malay States engaged in principal 11::gffilaiid32fiySlztgssl?er::e occupations. Male and female. y ’ (Table 5) Selangor, Negri Sembilan, and Pahang——have really been under British protection, although federa- tion was not actually brought about until 189S—twenty years after the treaty had been concluded. The non-federated states and Johore, although nominally independent, are also within the British sphere of influence. Thanks to the British occupation, the territory has been opened to agriculture, and good transportation facilities have been provided. The tin-mining industry has been so thoroughly developed, and has proved so successful, that it has yielded an annual revenue large enough to provide for many public works. Public Health Work in Malaya. Among the more impor- tant activities of any country are those that pertain to the health of the people. Public health work in the Federated States is fairly well established. There are a Principal l\/Iedical Officer at Kuala Lumpur, a Senior Health Officer in each of the four states, and a District Health Oflicer in each of the several districts within each state. In addition, there are a director for the Institute of Medical Research, a pathologist, a bacteriologist, a chemist, and two health officers in each state. The health work is so organized that general and district hospitals serve as centers. Fourteen of these are pro- vided and maintained by the British Government, and fifty-two by the Government of the Federated Malay States. There is also a Fig. 7.—Map of Java Black spots indicate where investigations have been conducted POPULATION AND LIVING CONDITIONS 7 Malaria Board and a Nursing Association. As for sanitary con— ditions, the water supply is good and the coolies on the estates are provided with proper conveniences. II. THE ISLAND OF JAVA The Territory and the People. In order that the findings of the Commission might be made more generally applicable through- out the Orient, the scope of the investigation was extended to include the islands of Java and Sumatra. In the urban communities of Java the native people live in kam- pongs, or collections of houses with fenced-in gardens shaded by cocoanut, sugar-palm, and fruit trees, and often inclosed by those city streets occupied by the shops, offices, or residences of Europeans. In the rural com- munities the people live in des- sas, or native villages which accommodate from 300 to 3,000 persons. These dessas are sur- rounded by rice sawahs and cane fields. The unhygienic habits of the people, and the lack of sanitary conveniences, in both urban and rural communities, are such as to be a constant menace to public health. A large propor- GIRLS WOMEN BOYS ”MEN tion of the men, women, and children make a practice of def— Fifi? 8.—Relatio_n between length ecating in the drains ditches of time spent in infected sawahs, or -’ . ’ rice fields, and numberof hookworms and canals, near public market h b 'd B V d . . ar OI'L . 3 sex an age groups. places, besnde railroads, along , , java country lanes, and in rivers and irrigation channels. Not infrequently they bathe their bodies and wash their rice in the same streams. 6: cc to o II) E i h. o I: h.) m E :7 z u; to < cc s” < III. THE FIJI ARCHIPELAGO General. For the purpose of checking up the findings of the Commission in the Federated Malay States, in Java, and in Sumatra, two members of the Commission spent three months in the Fiji Islands and there conducted extensive inquiries. 8 INTERNATIONAL HEALTH BOARD The low spleen rate of Tamils entering the Malay States at Port Swettenham from South India led to the belief that it would be possible to find in some parts of the tropics districts free from malaria, for although hookworm disease is practically universal in the tropics, malaria is not co-extensive with it. Indeed, it is known that Bar- bados and many of the islands of the Pacific—including the islands of the Fiji Archipelago—are entirely free from malaria. The fact that the studies of the Commission in the Federated Malay States had been very largely concerned with the effect of malaria and hookworm infection upon Indians, taken in connection with the fact that there were in the Fiji Islands a large number of free and indentured Indians who had lived there for from six months to thirty years, convinced the Commission that Fiji would serve admirably for purposes of control experiments. The island of Viti Levu, the largest island in the group, was selected as the field for intensive study. Climate of Fiji. The climate of Fiji is tropical but very healthful, for, although the heat of the sun is intense, it is tempered during the day by cool breezes from the south and east. At night it is frequently necessary to use a blanket. The heat is never so enervating there as in either Malaya or Java. Natives, both men and women, are of large stature and of great physical endurance. Their vigorous condition is certainly due, at least in part, to freedom from malaria. Moreover, the Indians of Fiji also seemed to be in better physical condition than those examined in Malaya. The Commis- sion did not find it possible to determine scientifically whether this was properly attributable to the more bracing climate of Fiji, or to the fact of their North Indian origin. Character of the Native Fijian. The native Fijian is not disposed to engage in sustained, monotonous labor, except to attend to the cultivation of his own taro beds in the village. This indisposi- tion may be due to either custom or temperament, or it may be due to the fact that he is a land-owner and does not feel the necessity of exerting himself continually. However, he is always able and willing to do work that requires theexercise of great strength spas- modically, as in the case of the boatman, the drayman, or the housebuilder. Indian Coolies in the Fiji Islands. The Indians in Fiji come from Calcutta and from the Madras Presidency. Their term of agreement is five years, and their wages are fixed by the Indian Government. During the period of their indenture they receive free medical attention in the plantation hospitals, which are in charge of European physicians. The value of this attention becomes evi- dent from a comparison of their condition with that of free or unin- dentured coolies, who have no such privilege of free medical treat- ment. The Government requires good latrine accommodations, and careful inspections are made by medical authorities to see that Fig. 9.—In the great struggle for subsistence in the beautiful island of Java, men and women become beasts of burden but are not brutalized in the process Fig. lO.——The hill sawahs of Java. Rice and potatoes are cultivated here. Hookworm infection was light Fig. 11.—One of the canals of old Batavia, Java. Here the people bathe, urinate, defecate, and wash their clothing and rice. Hookworm incidence, 95.2%; average number of worms, 49 Fig. 12.—Food being sold from the ground. of spreading worm infection One means POPULATION AND LIVING CONDITIONS II sanitary regulations are complied with. Although at the expiration of their term of indenture, theseIndians may re-engage for an extended period, they seem to prefer to acquire small holdings of from eight to ten acres and to settle on the land as farmers; or else they choose to go into business in a small way, as shopkeepers. Very few ever return to India, although continuous residence in Fiji for a period of ten years entitles them to free return transportation. The reason for their preference is evidently that in Fiji they enjoy greater prosperity than they do in their native country. This review of the lands visited and of the people studied is of course not exhaustive. It merely represents an attempt to provide a general background for the more detailed description of the Com- mission’s labors which is to be given in ensuing chapters. CHAPTER II ORIGIN OF THE INVESTIGATION Preliminary Inspection. Early in 1914 the General Director of the Rockefeller Foundation International Health Board made a tour through the Orient. His object was to observe conditions and gather data regarding the customs and habits of the people and the relation of these customs and habits to their general health and working efiiciency. The itinerary included Egypt, Ceylon, the Philippine Islands, and the Federated Malay States. Opportunities were afforded in Malaya to study conditions from Penang to Singapore, and data especially prepared in advance were made available for in- spection. A number of rubber and cocoanut estates were visited, and some 2,000 coolies were clinically examined. There were indi- cations on every hand of the universal prevalence of hookworm disease, as well as of malaria. Need for the Investigation. Considerable uncertainty was found to exist among the planters and physicians interviewed, in regard to the seriousness of hookworm disease as a menace to health and as a detriment to efficiency. While the limited amount of reli- able data available pointed to malaria as the principal disabling dis- ease on the estates, there was also much convincing evidence that on a number of these plantations hookworm infection increases and severe anemia results. The anemia which results from malaria cannot be distinguished from the anemia which is due to hookworm disease. The two dis— eases are in fact so complicated that the value of unverified conclu~ sions is rendered extremely dubious. In view of this large element of doubt, it was felt that in advance of any recommendation of expendi- tures for the relief and control of hookworm disease, there was real need for a scientific investigation by an independent commission, fully supplied with the necessary funds and equipment. Medical men were in agreement as to both the possibility of de— termining the relative importance of hookworm infection as a dis- ease-producing entity, and the desirability of settling this question before any considerable amount of work for immediate relief and ultimate control should be undertaken. Appointment of Uncinariasis Commission. The local repre- sentatives of the British Government were approached with reference to their attitude concerning the appointment of a commission of inquiry. It developed that the Government was not only friendly, but cordially sympathetic. As a result, it was agreed in conference at Government House, Singapore, that the first effort should be directed toward ascertaining the facts. The appointment of a com- 12 Fig. 13.—Laboratory of Uncinariasis Commission to the Orient, located at Kuala Lumpur, Federated hIalay States Fig. 14.~Interior of field laboratory, used by the Commis- sion in Java. The laboratory was placed beside a great cement open drain on one of the streets of the kampong. Huge floating fecal masses, so characteristic of rice-eaters, came floating down the drain. Cholera is usually present in this kampong Fig. 15.—Scene in Batavia. Here throngs of people come to wash their clothes and rice and to bathe in the sewage-polluted stream ORIGIN OF THE INVESTIGATION 15 petent commission of scientific investigators was authorized by the Board, and Dr. Samuel T. Darling, Dr. Marshall A. Barber, and Dr. H. P. Hacker were selected. Dr. Darling was made Chairman of the Commission and instructed to conduct studies in such places and in such manner as might be deemed expedient. Authorization was also given to employ the necessary clerks and technical assistants. Task of the Commission. A memorandum of instructions was prepared for the guidance of the Commission in the conduct of its investigations. As defined in this memorandum, the purpose and object of the Commission was ”to determine to what degree Uncinaria infection is a menace to the health and working efliciency of the people in the country under consideration.” The intimate relation found to exist between malaria and hookworm disease as disabling factors made it necessary for the Commission to devote almost as much time and study to malaria as to hookworm disease, in order to determine the relative importance of the two infections as causes of anemia. The Commission came to be known as the Uncinariasis Commission to the Orient. . CHAPTER III EXTENT OF THE INVESTIGATION The Commission assembled at Kuala Lumpur on June 2, 1915, and there, in the District Hospital, established permanent headquarters. There were 465 beds in this hospital; the daily number of sick aver- aged 334; the total admissions for the year 1915 amounted to 4,868. Most of the patients were suffering from dysentery, malaria, beriberi, ancylostomiasis, or tuberculosis. From these facts it will be evident that the Commission found plentiful material available for study. Much valuable and necessary work was done in the laboratory here, by way of training assistants and developing technical skill. They were given opportunity to study cases of anemia and to learn methods of treatment. For a month after arriving at Kuala Lumpur, the members of the Commission made a tour of the vicinity in order to familiarize them- selves with the new situation. It became evident at once that there was much malaria, everywhere and among all classes, and moreover that this disease was responsible for an enormous amount of acute and chronic disability. Malaria surveys were made in a number of neighboring localities, in the course of which anophelines were dis- sected to determine the presence of malaria plasmodia, and the spleen and parasite rates of patients were taken and recorded. Plan of Action. The Commission pursued the following plan in conducting its inquiry: (1) It studied by clinical and laboratory methods the cause of anemia among the -‘patients who were admitted to a large general hospital. (2) It examined at the detention camps at Port Swettenham and Singapore a large number of Tamil and Chinese immigrant coolies from southern India and southern China. At Port Swettenham 2,261 Tamil coolies were examined and at Singapore 700 Chinese coolies. (3) It treated with chenopodium, or some other vermicide, a con- siderable proportion of those who on examination showed evidence of hookworm infection. Of the 2,261 Tamils examined at Port Swettenham, 35 were treated individually, and 391 in groups of 40. Of the 391 treated in groups, 308 received two treatments of chemo- podium, and 83 two treatments of thymol. (4) It made every effort to trace the treated cases to the several estates and mines where they worked. This was for the purpose of re-examining them in order to determine the effect of residence in the Federated Malay States (and consequent exposure to hookworm infection and malaria) on their general health and working efiiciency; and at the same time to estimate the relative effect of the two dis- eases in causing anemia, and to determine the value of treatment. 16 Fig.\16.—Group of night—soil coolies in the Federated l\/Ialay States. The hemoglobins of the men, from left to right, were 47, 65, 80, 85, and 92, respectively, or 74 average; the numbers of hook- worms harbored were, respectively, 676, 562, 256, 280, and 649, or 485 average. The blood of all five was negative to malaria plasmodia. The spleens of the third and fourth men were enlarged; those of the other three were normal. The condition of these coolies is often good because, being pariahs, they suffer no dietary restrictions Fig. l7.—Malay boys’ school, Kampong Bharu, Kuala Lumpur. Forty-two boys were treated here. They remained away from their homes, taking their meals and sleeping in the school house for four days. Showing how amenable to discipline are these sons of “the mildest men that ever scuttled a ship or cut a throat” ,9...— EXTENT OF THE INVESTIGATION 19 Work at Port Swettenham. All incoming Tamil coolies were detained at the quarantine camp at Port Swettenham for a period of one week. Nearly all of the Tamils examined (for plasmodia in the blood, and for ova in the stools) were found to be in a fair condition of health, and remarkably free from ulcers and other skin diseases. Arrangements at the camp were very convenient for the investiga- tions undertaken. Twelve inclosures were arranged in a circle around a central administrative building, and were so constructed as to be quite independent of one another. Each had its own water supply and its own water-flushed latrines, with proper drainage system. A common kitchen was situated in the central open space. Thanks to the generous co-operation of the authorities, one of the buildings was temporarily converted into a laboratory with adequate facilities; also an excellent ward in the camp hospital was made avail- able for the use of the Commission. As an aid to future identification, a history of each coolie was taken. A record was kept of his father's name, his own name, his age, his caste, his personal characteristics, and the village of his origin. A spot map was made not only showing this place of origin, but also giving the following data: anemic cases; whether or not the coolie was found negative to hookworm infection after three examinations; enlarged spleens; and enlarged spleens in relation to anemia. The name or number of the estate to whiCh each coolie was going was placed on a disc provided by the immigration authorities. If at any time previously the coolie had ever left India for any other country, he was rejected for the purposes of this investigation. The cases chosen for treatment were all scheduled to go to estates that had selected twenty or more, a number sufficiently large to justify the Commission in paying a visit to those particular estates. Work on Estates. After an interval of‘ from 30 to 42 weeks the coolies who had been examined at the ports of entry—or as many of them as could be traced—were followed to the several estates to which they had gone to work. Fourteen estates were thus vis- ited, and 264 coolies were identified and re-examined for signs of anemia, malaria, and hookworm disease. Statistics were tabulated with reference to both those who had, and those who had not, been treated for hookworm infection at Port Swettenham, and who, sub- sequently (on the estate) either did or did not show signs of malaria. This work of investigation on the estates was begun about the middle of June, 1916, and was concluded about the end of August, 1916, a period of approximately two and one-half months. The re—examination, on the estates, of cases treated at Port Swet- tenham showed that the benefit of treatment for hookworm disease was nullified on the flatlands estates, as a result of re-infection, but that on the hilly estates the beneficial results of treatment were maintained, provided the coolies did not contract malaria. This disease was found to be the chief anemia-producing factor on these latter estates, while hookworm infection was found to be relatively 20 INTERNATIONAL HEALTH BOARD unimportant. The contrary proved to be true on the estates located on flat coastal plains. Work among School Children, Mine Laborers, and Others. In addition to the work of investigation carried on among coolies at detention camps and on estates, the Commission conducted a num- ber of special studies in the Federated Malay States among children in schools, laborers in mines, patients in hospitals, inmates of prisons, and night-soil coolies. Fifty-eight children were treated at the Convent School at Kuala Lumpur. These children lived under fairly constant conditions, were well nourished, received good care, and in their surroundings were comparatively free from exposure to malaria or hookworm infection. They were only lightly infected with the latter. No definite relationship was established between the duration of resi- dence and the number of worms harbored. Two Malay schools for boys and one for girls were visited and the children examined—83 boys and 40 girls. Two of the three schools, one for boys and one for girls, were located at Kampong Bharu, a suburb of Kuala Lumpur. The surroundings of these schools rather favored malaria and, as there was not a little pollution of the soil, there were plenty of opportunities for direct exposure to hook- worm infection. There was evidence of association between worm- count and hemoglobin content whenever the number of worms harbored was above 150. Work among Night-Soil Coolles. For purposes of compara- tive study, 35 coolies employed on the public roads of Kuala Lumpur and 90 coolies engaged in collecting, transporting, and burying night soil were examined. Most of these laborers, particularly those in the latter group, belonged to the pariah class of Tamils. Both groups were infected with malaria and hookworm disease. Naturally, the night-soil coolies were directly exposed to hookworm infection, and examination showed that they had a high incidence of Necators, as well as a high incidence of Ancylostomes derived from the feces of Chinese. Duration of exposure to infection—that is, the length of the period during which the laborers were employed at this kind of work —bore a direct relation to the number of Ancylostomes harbored. Work among Laborers in a Tin Mine. The Commission visi- ted a tin mine and examined two hundred workers in an attempt to discover the degree of hookworm infection present, and to determine its effect on the efliciency of the Chinese laborers employed in both surface and underground workings. It was not easy to get at the facts. The mine was operated by laborers under a contract which left them free to work as much or as little as they pleased. At the end of each shift they were paid by a headman for whatever they had done. Under these circumstances there was very little co-operation. Regarding the data obtained, anemia was not found to be present in any marked degree. The general condition of the workers was EXTENT OF THE INVESTIGATION 21 good; the ulcers which many of them had were probably occupational in origin. A comparison of these mine workers with a group of coolie prisoners in Taiping Jail showed that there were some in the jail who had lower hemoglobins than those who worked in the mine. Probably the explanation is that the less eflicient are elim- inated from the mines, while both the more efficient and the less efficient are to be found in the jail. Comparative tests indicated that the average hemoglobin percentage among underground work— ers was slightly less than among the surface workers. Examination of the stools showed a slightly higher percentage of hookworm infec- tion among the former than among the latter. There were very few cases of either malaria or dysentery, but all such cases showed a lower hemoglobin average as a result. Work among Prisoners and Patients. At Taiping Jail, 393 prisoners were clinically examined during the month of August, 1916, and 354 were chosen for treatment. Dysentery was found to be a decided factor in producing anemia. There was no opportunity for hookworm infection either in the prison or by means of the latrines connected with the prison. At the District Hospital at Kuala Lumpur, a charitable institu- tion, 588 patients were examined for plasmodia in the blood, and 524 for ova in the stools. Special groups of Europeans, Eurasians, Sikhs, Chinese, Japanese, and Tamil men and women were treated here and at the General and European Hospitals. At the Victoria Institu- tion, a school for boys, 500 students were examined. Control Investigation in Java and the Fiji Islands. Be- sides these visits made by the Commission to a number of places in several different localities of the Federated Malay States, one mem- ber of the Commission spent a month on the island of Sumatra inves- tigating methods of treating hookworm disease. . Afterward, this same member visited the island of Java, and for four months studied hookworm infection both with and without malarial complications, among the natives in urban as well as rural sections. Then, for the purpose of checking up the findings of the Commission in Java, Sumatra, and the Federated Malay States, two members visited an island in the Fiji Archipelago (Viti Levu) known to be entirely free from malaria. In the course of its investigations the Commission microscopically examined the feces of 3,776 Tamils, Chinese, Malays, Bengalese, Singalese, and Eurasians, and found that of this number 87.8 per cent were positive for hookworm ova. (See Table 6, page 125.) The labors of the Commission extended over a period of twenty-five months. CHAPTER IV METHODS OF EXAMINATION Two Principal Methods. The actual presence of hookworms in a person suspected to be infected may be determined either by micro- scopic examination of the feces for ova (smear and centrifuge |00 37.8 80 60 Z 9 p— 040 in u. E20 LL o w 0 2 we «)8 +— gzo 52 Z JV" WEE Lu cri'fi 8(a) u w V > D“ fie :8 :E I: a E; E a; x f5 _ Fig. 18.—Respective merits of microscopic examination and med— ication as means of revealing hookworm infection. All races. (Table 6) methods), or by vermicidal treatment and the recovery of worms expelled. The latter is the more accurate method. The present chapter will be devoted to an exposition of these methods of examination for determining in- fection; in the next chapter the technique of treatment, as tested by experience, will be discussed in detail. EXAMINATION 0F FECES FOR OVA Smear Method. There are two methods of examining feces for hookworm ova—the smear method, and the centrifuge method. The smear method as described below was used most often in the course of the Com- mission’s investigations because, owing to its simplicity, it enables the microscopist to make, with the least expenditure of time, an estimate of the number of ova in each specimen. Microscope slides (2" x 3”) are prepared in advance. Each slide is labeled so as to correspond with the number given to the particular specimen under examination. An area is inclosed on the upper surface of the slide by means of a line drawn with a grease pencil. A mixture of glycerine and sat- urated solution of NaCl, in equal parts, is dropped into this area along with a portion of feces which has been diluted with water and thoroughly stirred, to insure a fairly uniform distribution of the ova throughout the mass. Experience showed that the best results are to be obtained when the amount of feces is so large as almost to overflow the greased lines, and yet not so large as to be too opaque for microscopic examination. 22 Fig. 19.—Night-soil disposal. The buckets containing feces are brought to the burial place in bullock carts. Note the children (three) who daily accompany their parents. These coolies harbor six times as many A. duodenale as the road coolies, the worms being derived from the feces of the Chinese residents of Kuala Lumpur Fig. 20.~Night—soil disposal. Filling the trenches. Sur- face contaminated with feces, and one has to walk with the greatest circumspection. A guard is placed nightly to prevent the Chinese market gardeners from exhuming the buried night soil. The efforts of the guard are, as a rule, futile Fig. 21.—Night-soil disposal. Washing the buckets. The shore is heavily polluted. Hookworm larvae were detected here METHODS OF EXAMINATION 25 Ten or twelve of these slides, prepared by especially trained dressers, are then placed on a slide-holder constructed of a thin board, and brought to an expert microscopist for examination. The actual examination of ova was never intrusted to a subordinate. Because of the difference in specific gravity the worm ova always rise to the surface; then they are readily recognized. The action of the glycerine in clearing the fecal mixture more rapidly than it does the worm ova, makes the ova especially conspicuous. Centrifuge Method. The centrifuge method and a modifica— tion of the centrifuge method are both used. As in the case of the smear method, the centrifuge process involves, first, mixing a mass of fecal matter with water, according to consistency. The mixture is then placed in a test tube and centrifuged, after which the supernatant fluid is poured off. A saturated solution of NaCl is added; or, if glycerine is available, a mixture of equal parts of glyc- erine and a saturated solution of NaCl is added and thoroughly mixed. Then the mass is again centrifuged. Enough liquid is added to practically fill the tube. The ova are removed by means of wisps of cotton, which are mounted and examined under a microscope. A modification of this method of removing the ova—which was also used—is the following. Wisps of cotton, with one end twisted into a tail, or pieces of cotton string frayed at one end, are prepared in advance. When one of these is placed in the test tube the frayed portion floats to the surface of the fluid. Two or three drops of a 2 per cent solution of ordinary nutrient agar are then dropped into the tube. It is better to do this when the melted agar is still hot. If glycerine is not available, saturated solution of NaCl will answer. The agar will float and solidify as a disc, and the ova, rising, will adhere to this disc. When the tubes, thus prepared and labeled, are placed in a rack and brought to the microscopist, the agar disc is lifted off without difficulty by means of the twisted end of the cotton wisp. The disc is then placed on a slide, fecal surface uppermost. A cover glass is adjusted and pressed down, and the preparation is ready for exami- nation. Two discs may be placed on one slide. It will not be found difficult to detect the ova, for if they are not found on the surface of the disc they will be found but very slightly imbedded. It is better to examine these preparations before the ova have had an opportu— nity to become transparent—say within an hour—for in a condition of transparency they are more difficult to detect. In populations in which there is a large percentage of persons positive to hookworm, this method offers the advantage that as many as thirty cases an hour can be examined. When a specimen is found negative upon examination, further specimens can of course be obtained on subsequent days, for purposes of re-examination. But in a population heavily infected, such re-examinations of apparent negatives are not worth while. For example, of the 2,262 cases examined by the Commission at Port Swettenham, 64 who were 2 6 INTERNATIONAL HEALTH BOARD apparently negative were re-examined; but the results of these examinations were so slight as to raise the total positive by only 1.5 per cent. In one of the jail series, 349 cases were examined and 73 found to be apparently negative; but upon re—examination on subse- quent days, only 11 of the 73 proved positive. The reliability of feces examinations for ova can best be determined by comparing the percentage of positives thus obtained with the percentage obtained by recovering the worms expelled by treatment. In the work of the Commission the results secured by the two kinds of examinations were not strictly comparable. For instance, in some cases dealt with, the group examined for ova was not treated at all; in others, the treated cases had not previously been examined for ova. The feces examination usually included all cases which could be obtained, irrespective of the degree of anemia; in the treatment cases a larger percentage of infected persons than of non- infected were probably selected. But in a general way the results from the two groups are compar- able. The percentages of positives obtained by the two kinds of ex- aminations are compared by races. (See Table 6, page 125.) The differ- ence shown by the totals, 4.6 per cent, by no |00 means fairly represents the superiority of the 90 treatment method, because the different races 80 show different rates of infection, and because the numbers examined by the two methods 70 u are unequal. Where a percentage of 80 was ‘2 60 obtained by the method of examination for 250 ova there is little doubt that a percentage of g“ 90 or more would have been obtained by ‘a‘ the method of treatment. A more exact comparison is obtained when the same individuals who are examined for ova are subsequently treated. In all, 209 cases were traced in which both sorts of exam- PERSONS PERSONS inations were made. The results of these ex- -W:E:;YVBEMH:::ATWE aminations are shown in Table 7, page 126. txmmmmwnmmm Reference to this table will show that the m”§éll¥fv?lf¥clll§ll4lfalmu method of feces examination failed in 8.1 per mmmummyrmuxmmmo}. centofcasesinwhichitwaslaterdemonstrated -NZS”:TI"‘I‘EE::‘;::;::IMW- that hookworms were present, and-that ova ‘ mmmxouammmrm were found in 2.4 per cent of cases 11'] Wl’HCh treatment failed to detect any worms. Second specimens of stools were available for re-ex- amination for ova in the case of only one of the 17 negatives. The species and number of Fig. 22.—Relative ac- curacy of hookworm di- agnosis by feces exam- ination, as indicated by . laterrecoveryofworms; hookworms found in these 17 cases are given 209 cases treated irre- spective ofresultof fecal examination. (Table 7) in Table 8, page 127. It will be seen that 3 of the 17 cases showed no female worms at treatment, and that 12—or nearly three- METHODS OF EXAMINATION 27 fourths—had two females or less. Apparently a single thorough examination of a stool fails only in the case of lighter infection. Vermicidal Treatment and Recovery of Worms. The proced- ure followed in examination by the method of vermicidal treatment and recovery of worms expelled, was practically the same in all cases. The people were called together, physical and clinical examinations were made, and representative cases were selected on the basis of hemoglobin estimations. On the morning of the day previous to treatment patients were allowed their usual diet; in the afternoon they were given some rice gruel and a half—pint of milk. At 5:00 P.M. a purgative was given—six drams of saturated solution of magnesium sulphate, or one ounce of sodium sulphate, or one ounce of castor oil. On the morning of treatment all food was generally withheld, although in some cases a little milk was permitted. The first dose of the vermicide was given at 7:00 A.M.; the second and third doses were given at hourly intervals thereafter. Two hours after the last dose of the vermicide a second purgative dose was administered, corresponding to the one given the night before. At 12:30 noon, the patients were allowed to drink milk, and in the afternoon they were given a little rice or bread. The next day they were allowed to have rice and curry, but vegetables with coarse fibres were prohibited because they interfered with the search for worms. If a patient remained constipated the purgative was repeated. Patients were enjoined to remain prostrate for a certain period after the adminis- tration of the vermicide. When chenopodium in the pure state was given, it was adminis- tered in hard gelatine capsules, which were filled at the time from a standard pipette. When an emulsion of oil of chenopodium in acacia was given, it was prepared fresh on the morning of the treatment. The bottle was well shaken before each dose was given. Doses, measured with a measuring glass, were given and were followed by a drink of water. No separate purgative was required when the emul- sion contained castor oil. Thymol also was frequently used in order to test the relative value of different vermicides. After the contents were finely ground and weighed, capsules holding individual doses were filled on the day previous to treatment. Varying amounts of different kinds of medicament were given for a first treatment; then, after an interval of from seven to ten days, a second treatment was given—usually consisting of a full dose of chenopodium (3 x 1 mil).* The efficacy of the treatment was deter- mined by noting the percentage of worms removed, careful search being made of four or more stools submitted by each case. This search for worms naturally proved to be a tedious and laborious process. Identification of Specimens. At the time of examination a numbered metal disc was attached to the wrist of each patient. At the completion of the treatment he was given a vessel to which his *Qne mil is equivalent to one thousandth part of a milliliter, i. 9.. one cubic centimeter. 3 28 INTERNATIONAL HEALTH BOARD name and register number were attached. It was always found pref- erable to use enameled or agate vessels. These receptacles were thoroughly washed and dried after each using. Rigid military discipline was instituted, to avoid any possible mixing of the feces of different .cases. In jails, where each person was confined to his own cell, it was comparatively easy to avoid confusion. In hospital wards the vessel was placed at the patient's bedside and defecation was supervised by a dresser, who was given instructions to prevent the use by any patient of a vessel not his own. The patients themselves were also given explicit instructions. They were drilled in remembering their numbers, and in taking their places in right numerical order for treatment and for changing of vessels. 'In the case of children this drilling was facilitated by schemes of rewards. The possibility of error from mixing of stools was altogether elimi- nated in one series by the device of giving each patient, at the time of treatment, a dose of small glass beads. These beads differed in color and size, and only one sort was given to each patient. For three or four days patients continued to pass these beads, and since there was no mixing of the different kinds of beads in the stools it is safe to say that there was no mixing of feces. In the whole series of treatments the degree of error due to the mixing of feces of differ— ent persons must have been negligible. The procedure followed was to have the feces brought to the place of examination twice daily, at about 7: 00 A.M. and again at about 2:00 p.141. Each patient usually brought his own specimen. When the patients entered the laboratory, the numbers on their wrists and on the vessels were compared and checked, and a slip of paper with the same number was placed in the vessel with the feces. All patients then received clean vessels, properly numbered. A record was kept of persons who brought no stools, and an additional purge was given to them when it was considered necessary and desirable. Washing of Stools. A regular routine was followed in the washing of stools. Those that were soft or fluid could be washed at once; those that were more compact had to be mixed with water and stirred until soft. When a tap was available, the washing was done in the sink beneath it. Usually, however, there was no water piped to the laboratory, and it was necessary to use a stream siphoned through a rubber hose from a large container placed several feet above the ground. The washing was then done by means of a jet of water played into a large brass wire sieve (with a mesh of 50 to an inch) into which the contents of the vessel had been poured. In order not to force the worms through the meshes of the sieve, it was found advisable to use a stream of moderated force. The regulation of the stream was readily accomplished by means of a pinch—cock at the lower end of the hose. The operation was always closely supervised so as to prevent splashing and consequent loss of ——_-.‘ Fig. 23.—Prisoncrs in Java jail. Treatment squad chang- ing “jcrrics” Fig. 24.—Dr. Darling making the hookworm survey in Batavia jail Fig. 25.—Squad N0. 3, Java jail. Spleen rate, nil; parasite rate, 21.8%; hookworm incidence, 95.8%; aver- age number of worms, 54; average hemoglobin, 94.6%; malaria, mild Fig. 26.—Squad N0. 2, Java jail. Spleen rate, 70.8%; parasite rate, 12.5%; hookworm incidence, 100%; aver- age number of worms, 139; average hemoglobin, 44.8%; malaria, severe METHODS OF EXAMINATION 31 material. Care was also exercised to provide against worms adhering to the sieve and being carried from one stool to another. After this washing process, the worms, the remaining insoluble portion of the stool, and the labeled slip were all rinsed into the vessel bearing the number of the patient whose stool had been examined. The washed stool was next distributed into photographic develop- ing trays, a small portion into each tray. A dark brown tray was found to furnish the best background for the worms. These were then picked out with needles or forceps and placed in properly num- bered petri dishes containing normal salt solution. Frequently the trays were examined and the worms removed by assistants; but a member of the Commission always made a re-examination, sometimes on both a dark and a light background. It was possible for one mem- ber of the Commission to inspect and check up the work of two or more assistants, of course provided the actual number of worms which had to be picked out was not too great. The original numbered slip which served as a label was placed, number side up, under the cover of the petri dish. This paper slip remained in direct contact with the contents of the stool, from the time the vessels were first received up to the time of the final counting and recording of the worms; it proved very effective in preserving accuracy. At least four stools were collected from each person. But the number that had to be examined was usually greater than that, for the series of washings in any one case was never considered com- plete until two consecutive negatives had been obtained. It is always highly important to expel the last worms, because the proportions of different species and sexes vary according to the interval following treatment. Finally, the excess salt solution was drained from the petri dishes; the worms were then killed by flooding these dishes with boiling alcohol (70 per cent). As Lane has pointed out, when scalded the worms become rigid and assume the shapes that are characteristic of the different species. Differentiation is thus rendered comparatively easy and the worms can be rapidly counted. The Commission kept careful records of the numbers and sexes of the different species expelled and recovered. CHAPTER V METHODS OF TREATMENT Routine Treatment. The routine technique of treatment was, first, to give one treatment with the remedy which was to be tried, and then to give chenopodium in the subsequent treatments. The first treatment was called the trial treatment, and the second treat- ment was called the test treatment. Experience convinced the Com- mission that this second treatment should never be given until after the lapse of one full week. After the first, or trial, treatment the worms expelled were collected and counted. One week or more after the second, or test, treatment the stools were examined for ova, and if they were still found to be positive other treatments were given until they proved negative. Next, the number of worms expelled was counted,and it then became pos- sible to determine both the per- centage of the worms removed by the first treatment and the number of cases actually cured. By way of preparation for treatment the patients in a cer— tain series of experiments (at mayo: 0000 ._.~i,. coo tomed fare at 11:00 A.M., but at the afternoon meal—which was usually served at 3:00 P.M. -—-they were given only soft rice gruel. At 4:00 P.M. a concen- trated solution of magnesium THYMOL mmun sulphate (one ounce of the salt) Pmtuuctnrnovmvmumummomm was given as a purge. On the nmovrommmmum following morning the patients had milk instead of their ordi- nary meal, and then the treat- ment was given. The last dose of medicine was followed, after an hour's interval, by a second purge of magnesium sulphate (one ounce). After the purge was given, the prisoners were again locked up in their cells, kept away from work, and allowed out only for exercise. The stools were collected at 2:00 P.M. on the day of the treat- ment, and at 7:00 AM. and 2:00 P.M. on the two days immediately following. These stools were washed and examined for worms until 72 hours had expired, and usually during this period six stools per 32 o 2 K S ":x’ .— f3 8 D E40 I ‘52 bl ‘3 p- E 32’ ‘6.” Fig. 27.—Comparative effect of thymol and chenopodium on two species of worms. (Table 9) Taiping Jail) had their accus-a METHODS OF case were obtained. However,if at the end of 48 hours any patient had two consecutive stools with no worms in them he was re- leased, always provided that at least four stools had been washed and examined. If at the time of any of the regular routine wash- ings, a patient did not have a stool, he was immediately given another saline purge. Relative Efficacy of Various Methods of Treatment. A considerable number of experi— ments (twenty-one separate se- ries) in the administration of vermicides were conducted by the Commission, in the District Hospital at Kuala Lumpur and elsewhere. The particular ob- ject was to reach a scientific con- clusion as to the quantitative value and relative merits and 3 35 313 E so 5 g 25 :0 22.2 g; 20 E; I5 :3 g3 I0 E E 5 2 7 E L2 ' I.5 g-onlel 10 MILS L5 MILS OJSMILS cnmomu .cumopomum CHENOPODIUM - 9o GRAINS - so GRAINS -4o GRAINS THYMOL THYMOL THYMOL meERIORITY OFCHENOPODIUM IN REMOVING NECATORS - SUPERIORITY 0F CHENOPODIUM IN REMOVING ANCYLOSTOMES TREATMENT 33 EFFECT ON ANCYLOSTOMES EFFECT ON NECATORS _,.I Ila» IIIAI | an Is: M III Ian I; _‘§II III I gull | ' | | | | PERCENTAGE REMOVED OF TOTAL WORMS .. '-:I| MAXIMUM DOSE MAXIMUM DOSE Two-Tumos mmuu Dos: :‘ : mun-ummsmnuu ms: :3: ONE-OWNER mmuu DOSE .z:-: rvmumos mmuu DOSE 3."... rounaumms mxmuu DOSE ' ONE-QUARYER mxmuu DOSE ONE‘HAU' MAXIMUM DOSE ONE-HALF MAXIMUM DOSE mmnmmmnmmmmmmmmn manna Itmouv mmma uni-woman Fig. 29. —Superior efficacy of Chenopodium, as compared to thy- mol, in removing more resistant worm species. (Table 11) Fig. 28.—-lillect of full and res duccd dosages of thymol and oil of Chenopodium in expelling two species of worms,trial treatment. (Table 10) efficacy of differently graduated doses of Chenopodium and thy- mol for routine treatment. The results of these numerous experi- ments can be summed up in a few paragraphs. Chenopodium in small doses proved to be more efficacious than small doses of thymol; also it showed a satisfactory eflicacy in a greater range of doses. While, dose for dose, both drugs showed about equal efficacy in removing Ne- cators, Chenopodium was quite superior to thymol in remov- ing the more resistant species of hookworm, i. e., Ancylos- tomes. (See Table 9, page 128.) Chenopodium also was more effective in removing other worms, such as Ascaris and Trichuris. There was failure to cure the patient (by removing 34 INTERNATIONAL HEALTH BOARD all hookworms) in 23.6 per cent of the cases treated with thymol, but in only 7.6 per cent of the cases treated with chenopodium. Better results are obtained from chenopodium when it is given in the original form of an oil than when it is prepared as an emulsion. On the other hand, better results are obtained from thymol when the drug is especiallypreparedin an emulsion than when it is administered in the form of a powder. The explanation is that chenopodium, a penetrating oil, on being received into the system is more uniformly distributed throughout the intestinal contents than is thymol when given as a relatively insoluble powder. The half-maximum dose of chenopodium (.5 mil three times, or a total of 1.5 mils) is, in the experience of the Commission, the best treatment as a routine vermicide. For while it does not have the toxic effects of the full dose, it was found that it will in two treatments remove about 99 per cent of all the worms present. A single treat- ment of 3 mils of chenopodium gave the best results of any single treatment tried; but the 90—grain dose of thymol was only slightly inferior in results. Both effected very satisfactory removal of worms. In Tables 10 and 11, pages 129 and 130, are indicated the effects of varying dosages of these two drugs upon Necators and Ancylostomes. Among the prisoners at Taiping Jail further experiments in treat- ment were conducted. Altogether 393 prisoners were treated, for the most part in groups of ten. ‘00 In addition to the customary 90 treatment with chenopodium (3 80 mils in 3 doses of 1 mil each) 7:: and thymol (90 grains in 3 doses of 30 grains each), a num- °° ber of experiments were made 5,, with beta-naphthol (20 grains in F ” capsules), with eucalyptus (30 5 minims), with chloroform (45 2 5° minims), and with castor oil (12 ‘a‘ 20 drams divided into 2 doses of IO 6 drams each). (See Table 12, o 0.0 page 131.) °§$g °§3§ o§g£ egg The cases of treatment were ‘3-2 ‘3V% ‘5‘“? J-E’ chosen at random. In the sta- 9 Eg g? g tistics no comparisons were made g $2: 5‘ §E§ between Chinese, Tamils, and a §§§ E; Sg- Malays, for the reason that 8‘3 Chinese harbor fewer worms -W°RM5RE"°VED NCASES CURED than either Tamils or Malays, Fig. 30 ——Efficacy of various ver- and for the further reason that micides in expelling hookworms and they harbor a much larger effecting cure. Worms removed by percentage _ 0f Ancylostomes. entire treatment; cases cured by Statistics With reference to the trial treatment. (Table 12) relative efficiency of different METHODS OF drugs used in the treatment of the respective groups mentioned would be invalid because, as the Commission discovered in the course of its investigations, it is more difficult to obtain a high percentage of worms expelled when few worms are harbored than when the number of worms is great; moreover, Ancylos- tomes are much more tenacious than Necators, and hence more difficult to expel. The different races, it must be borne in mind, have different worm formulae. The efficacy of chenopodium continued high even when the dose was reduced to one-quarter TREATMENT 35 9|.6 QD O on o ‘3 O PERCEMIAGE 0F WORMS REMOVED ' — N U ‘ U‘ 5‘ O O O O O O zeso zosn 96 I53 WORMS WORMS WORMS WORMS 23 39 23 39 CASES CASES CASES CASES 0 EFFECT ON EFFECT ON NECATORS ANCYLOSTOKS of the maximum dose; on the other hand, the diminution of m THYMOL 40 GRAINS EACH DOSE - CHENOPODIUM [.5 MILS EACH DOSE the dose of thymol resulted in a IOO 90 BO 70 r; so ‘0’ o E 5 a. 40 30 20 IO 0 .zmsrsmusts; must a 5 7,032 nmvmsamnsmms 5: gig; 23% Egg ggg End E2}: “:0 Egg-E 351 $35 022 3,__ g ;*E "’3 g 3% 23 a» 53. E - a :2 2x5 go 33: gig: JO 2.1 W >— gssz égzsésga °< .._., ._, 3 :2: S252 2§§§ Fig. 32.—Worms expelled and cases cured by two half-maximum- dose treatments of chenopodium, as compared with two 20-grain treat- ments of thymol in various forms. (Table 14) Fig. 31.—Hookworms expelled by two treatments of smaller than maximum doses of thymol and chenopodium. Two trial treat- ments. (Table 13) rapid falling off in efficacy. Two treatments of the half- maximum dose of chenopodium produced better results than one full maximum dose; in fact, the highest percentage of worms re- movedwasobtained bythis treat- ment—99.6per centof Necators, and 91.6 per cent of Ancylos- tomes. Two treatments with a smalldose of thymol did not pro- duceagoodsummationofresults. Test votes taken clearly indica- ted that nearly all the patients preferred chenopodium to thy- mol, as being less unpleasant to take. For these several reasons, thymol was deemed less suitable for usein general treatments, and particularly in the treatment of children. (See Tables 13 and 14, pages 132 and 133.) 36 INTERNATIONAL HEALTH BOARD Another series of treatments (eight in number) was given in order to determine the action and results of eight different doses of cheno- podium. All the patients were Chinese, and in all cases there was uniform preparation. These experiments showed that 3 mils of chenopodium in freshly prepared capsules, administered in doses of 1 mil, 3 times, 'at hourly intervals, gave by far the best results; 98.9 per cent of all the worms present were removed, and in 82.4 per cent of all the cases treated cures were effected. (See Tables 15 and 16, pages 134 and 135.) The 'superior efficacy of freshly prepared hard gelatine capsules of chenopodium, as compared with the manufactured soft capsules, was demonstrated by two series *1:- . ~. .1 3' ar:[ I ofexperiments. Withone group N of patients the manufactured so _ I capsules containing chenopo- so 5 ._ a dium were used, but with the 4° {3| result that only 66.4 per cent : - Q] of the worms present were ex— ,0 m ... " w pelled. Then the chenopodium, o .2. J; " "El extracted from manufactured gé Egg g; §§ E capsules which have thick, ‘ °3 83 :§ :3 2 if! ’2 tough gelatine walls, was placed 5 E; g E” g: ghl‘gg 5%; in freshly prepared capsules. ”2 E: g g; 23 g; E; gig These were administered to g; :3 3 a; E 25%“ Egg another group, with the excel- ;g EE E Ea‘ E5 gilg‘gfllgg; lent result that 97.9 per cent E "E g." 3E 3g EEIEQEEE— of the worms present were ex- gE g; g; gs Ea E5632; 2: pelled. Care was taken that all g; SE §g “,5 5g Saga; 73% the patients in these groups re- 3 5" 5 fig 3;? 5% 23233“; ceived exactly the same 'diet and 5 s 5 58 5.. 58 55! as r exactly the same previous purga- -WORM5 REMOVED -CA5[5 CURED . tron. (See Table 15, page 134-.) Fig. 33.—Worms expelled and The Commission wished to cases cured by chenopodium m vari- l h h . d ous doses. Single trial treatment. earn w et er, in or er to get (Table 15) satisfactory results, it was neces— sary to administer the chenopo- dium in three separate doses. Experiments were therefore made on a series of 30 cases, a single dose of 2 mils being given. The inter- esting result was that 95.8 per cent of the total number of worms present were removed, and 70 per cent of all the cases treated were cured. (See Table 15, page 134‘) Relative Costs of Treatment. An attempt was made to esti- mate the relative costs of treatment by chenopodium and by thymol. Figures Were preserved and tabulated, based on actual experiments made among sixteen different groups. At the time of the particu- lar treatments mentioned (February, 1917) the price of chenopodium was 1.84 cents per mil, and the price of thymol was 0.15 cent per M ETHODS OF TREATMENT 37 grain. The most satisfactory re- |00 sults, as far as the removal of 90 worms was concerned, were ob— 80 tained with one treatment of 70 chenopodium—3 mils, adminis— .— tered in 3 doses, each dose con- 5 6° sisting of 1 mil. On this basis, E 50 the cost per individual for the ‘L 40 chenopodium treatment there- 30 fore amounted to 5.52 cents. Proper comparison of costs can 2° be made only by using the dos- '0 age of thymol which proved to o . A- be most effective in removing (19 CASES: (19 CASES: (9 CASES: . 639 wows) 2384w0RMS) 94o WORMS) worms, VIZ., one treatment con- sisting of 90 grains, administered $833???" 406RNNS IN [DRAM IN - - POWDER 3 POWDER 3 1n 3 doses of 30 grams each. On TIMES.0R “MES'OR TIMES,“ this basis the cost of the thymol 9° GRAINS ‘20 GWNS 1309“"‘5 treatment perindividual was 13.5 THYMOL cents. It will therefore be seen - wows REMOVED m CASES CURED that treatment with chenopodi- Fig. 34.—Worms expelled and um COS“ less than one-half as cases cured by thymol in large doses. much as treatment With thymol. Single trial treatment. (Table 16) These data involve a considera- tion that is of importance eco- nomicallywhen mass treatmentof populations numbering millions is contemplated. (See Table 18, page 138.) After-efiects of Treatment. Observations were made with re- spect to the after-effects of treat- ment, such as dizziness, unsteadi- nessof gait (drunkenness),inabil- ity to rise, semi-comatose state, tingling of hands and feet, deaf- ness, burningin the stomach, and 83 headache. All of these,except the pmcffl‘ngfi nmovgo last two, were more commonly TOW-WW“ PRESENT complained of after the use of chenopodium than after treat- ment with any other vermicide. ° 5 8 S 3 8 S 2', 8 8 PERCENTAGE m THYMOL - CHENOPOD'UM (SeeTable19,page139.) Streaks Fig. 35.—Cost of thymol and of blood in the vomitus were chenopodium, with comparative occasnonally “Oth- These-were eflicacy based on worms expelled. probably due to the strain 0‘ (Table 18) vomiting, whether thymol or 38 INTERNATIONAL HEALTH BOARD chenopodium was used. Giddiness was always experienced, usually after the second dose, by all persons; it was more marked among men than among women. Not infrequently all the men would be lying down, giddy, after the third dose, while the women would be sitting up, talkative and cheerful. The manifestation of this minor phy- siological symptom was always to be desired, since it was in- dubitable evidence that the drug had been taken. Experience with regard to the after-effects varied among the people treated in the different localities. The more severe symptoms were very rarely complained of by the dessa u people in Java, who received treatment with chenopodium as an emulsion. For example, only one out of 175 persons so treated complained of deaf- ness. On the other hand, in a jail where the prisoners were treated with the raw oil of - CHENOPODlUM chenopodium in capsules, from Fig. 36.—After-effects of thymol 16 to 20 per cent complained 0f and chenopodium — incidence of deafness. deafness. (Table 19) In a hospital ward it was somewhat difficult to ascertain the degree of discomfort experienced, for each person was very likely to answer a question just as the one before him had answered it. In order that this possibility of error might be obviated, all the men on one side of the ward would be given magnesium sulphate and all the men on the other side would be given castor oil, both before and after the treatment with chenopodium. It was observed that giddiness and deafness were more often experienced by the men who had been given castor oil than by those who had been given magnesium sulphate. At the time of the “parade,” when each man had to rise, pick up his pot, walk out to the veranda, and exchange the pot for a fresh one, it was quite noticeable that the castor oil group contained the men who were suffering more severely from the effects of the drug. Sometimes they were unable to walk, or even to rise from their beds, without assistance. Among the immediate after-effects of treatment by vermicidal drugs may be noted the effect on the hemoglobin of the patients. A temporary fall, or net loss, was observed after treatment by cheno- podium when the normal hemoglobin of patients was from 61 to 70 per cent. Similarly a net loss in erythrocytes was observed after NU>UIO~IG>W .0 9 o C 90 GRAINS ° CHENOPODIUM O PERCENTAGE OF CASES OF DEAFNESS AOGRAINS o CHENOPODIUM O 0.75MILS ° THYMOL 606RNN$ o CHENOPOMUM 9 L5 MILS THYMOL 3DMH5 THYMOL METHODS OF TREATMENT 39 treatment by Chenopodium when the patient’s hemoglobin normally registered 80 per cent and over. In anemia cases, on the contrary, the increase of hemoglobin or erythrocytes was not interfered with by the administration of Chenopodium. In fact, both would mount almost immediately after treatment,and within a week would return to normal. Relapse cases of malaria following the administration of Chenopodium were examined, in order to determine whether or not the relapse might be due to an attack of malaria superinduced by the drug. No relationship of cause and effect was indicated. 90 Excretion of Chenopodium 80 and Albuminuria in the Urine. Investigations were un- 70 dertaken to ascertain the possi- 60 ble toxic effects of Chenopodium upon the kidneys, as well as the amount of absorption and rate 40 of excretion of the drug. The so presence, or absence, of al- 20 bumin in the urine is determined by the heat and acetic acid test. '0 To find the presence of cheno- 0 podium some urine is pipetted upon a surface of concentrated nitric acid. If resins are present a white ring, suggestive of albu- min, will form at the junction of the fluids. This ring, however, THYMOL HENOPODIUM differs from that which is formed by albumin, in that it forms at a slightly higher level in the urine and is most readily solu- ble in alcohol. In concentrated urine a pink ring forms at the junction of the acid and the urine, and this pink blends with the white ring that forms just above it. In albuminous urine the rings caused by albumin and resin form together, but on the addition of alcohol a cloud due to albumin still remains. Two or three drops of absolute alcohol are sufficient to dissolve the resin; but the albumin will remain until the concentra- tion of alcohol is reached, at which time its oxidation by the nitric acid takes place. Some attempts were made to obtain a quantitative estimate of the amount of resin present; the attempts were based upon the finding, by titration, of the amount of diluted alcohol re- quired to dissolve the ring. The results of these trials, however, were not sufficiently constant to be of any value. No attempt was made to determine gravimetrically the amount of resin present. The fact that greater absorption, as shown by greater toxic symp- toms, took place when castor oil was used as a purge than when 50 t.— Z N U (I N O. 40 GRAINS (so CASES) 1.5 MILS (52 CASES) (59 CASES) Fig. 37.——After-eflects of thymol and Chenopodium—incidence of albuminuria. (Table 19) 40 INTERNATIONAL HEALTH BOARD salines were employed, was confirmed by the relative size and opacity of the rings present. The test was made 6 hours after the castor oil had been given, in doses of 10 minims, 3 times, in soft capsules. The 5 cases to which castor oil was given were all positive, and had much heavier rings than the 5 cases to which magnesium sulphate was administered; among the latter, 2 showed no reaction. That more absorption takes place with the larger dose of cheno- podium (3 mils) than with the smaller dose (1.5 mils) was indicated by the greater toxic symptoms produced, and was confirmed by the incidence of the reaction in the urine and the opacity of the rings obtained. This was substantiated in two series of experiments. In one series, each of 26 cases was given 1.5 mils of chenopodium, and of that number 12, or 46.2 per cent, showed positive reactions. In the other series, each of 86 cases was given3 mils of chenopodium, and of that number 70, or 81.4 per cent, showed positive reactions. The rings were much heavier in the second series than in the first. That the excretion of chenopodium, particularly the resinous part, was slow (sometimes not being completed in five days) was also shown by a series of experiments. The length of time during which the reaction lasts in the urine was determined in a series of 12 cases, each of which was treated with 3 mils of chenopodium. In 7 of these cases a reaction was obtained for as long as 126 hours after the administration. In 5 of the 7 cases no albumin was revealed by the boiling test throughout the observations—which were 90 made twice daily—and hence no 30 difficulty was presented in the determination of the presence 70 or absence of resins. Theother 50 2 cases did develop albumin, I’, but the presence of resin was I 5° ' f d f ' 1 1 ' '_ in erre mm a partla so ution 5 4° of the ring formed. 0 50 When the severe toxic symp- 3 20 toms, such as coma and deaf- or ness, occurred they generally 3 '0 were evident after the second :5, 0 treatment. In the earlier part Z of the work of the Commission, the second treatment was given on the fourth day, in order that the patients might be released within a week. But the results just indicated as to excretion CHENOPODIUM made it clear that this proced- Fig. 38.—After-efiects of thymol ure was not advisable. There andchenopodium—deaths. (Tablel9) was always the danger that the METHODS OF TREATMENT 4I second dose might produce toxic effects by accumulation, if given before all the drug from the first treatment had been excreted. Although no deafness or coma occurred after administration of the lower doses of chenopodium (1.5 mils), it is to be noted that the high- est dose of chenopodium (3 mils) occasionally produced these toxic effects on the nervous system. With even the highest doses of thy- mol, on the other hand, no serious toxic symptoms were noted— nothing more than giddiness. Among the after-effects of treatment by chenopodium, there was one case of exacerbation of symptoms of dementia praecox. Only two cases of death occurred as the result of treatment, and in both of these cases full chenopodium treatments had been given within four days. After these two fatal instances, and in all the later work of the Commission, the second treatment was never administered until an interval of at least one week had elapsed. Incidence of Vomiting. In some of these experiments there was vomiting after the first treatment only; in some, after the second treatment only; in some, after I ' both treatments; and in some, 90 after neither. When vomiting occurred it usually took place so directly after the second purge 7° was administered, and after the 60 second dose of vermicide. The 50 percentage of worms found 40 and removed, both Ancylos- tomes and Necators, varied con- 3° siderably in the different series. 20 This difference in the relative .o efficiency of the several doses 0 0.0 00 was probably due, at least in part, to the vomiting. Strong peppermint lozenges , were sometimes given in order to prevent this vomiting if possible. When there was such vomiting the drug was usually repeated; not infrequently the vomitus . Fig. 39.—After-effects of thymol contained portions of the ver- , . , micide. The amount of vom- and. Ichenopodium—inCidence of vomiting. (Table 19) iting varied considerably and interfered not a little with the efficiency of the treatment. It is quite possible that this reaction may have been due to the taking of food secretly obtained, or it may have been due to other and unknown causes. A certain amount of vomiting is always to be expected in the treatment of cases not under absolute control. At Taiping Jail, in the course of the experiments performed there, the dose of chenopodium which caused vomiting resulting in loss l0 CASES 20 CASES ()0 6RAIN$ l0 CASES in u 3 in o in E g u: GRAINS 19 CA$E$ 5 MILS IBOGRAINS l0 CA$ES 90 GRAINS 19 CASES THYMOL - CHENOPODlUM 42 INTERNATIONAL HEALTH BOARD of efficiency was not actually 100 reached, although 3 mils were 9° given. But in the experiments 30 ”I“ at the District Hospital at 7° Kuala Lumpur, 46.9 per cent of vomiting occurred with loss 360 of efficiency at a dosage of 2.8 g 50 4 mils. The heavier doses of E 40 ' thymol (120 grains and above) so removed fewer worms than the . 20 lighter doses, because the vom- iting that occurred reduced the '0 amount of drug retained in the 0k * "- . 6 CA E '19 CASES; IO CASES; (6 CASES: StomSCh 1? C0n51d§rablY below ZSWORMS)97WORMS)IO7WORMS)62WORMS) the quantity reqmred for the COMPOUND CALOMEL, efficient removal of worms. MIXTURE CASTOR MAGNESIUM 4'GRAINS. . . OF OIL. SULPHATE, MAGNESIUM Experiments With Purges. SENNAV 1% OUNCES. LOUNGE SULPHATE, In order to determine what Z'OUNCES "OUNCE WORMS REMOVED H t, "i ,th k'nd of ure e CC lany e I P g CASES CURED used had upon the value of the treatment, a series of cases were Fig. 40,—Experiments with vari- treated in which the purge ad— ous purges in chenopodium [reap ministered was varied. To one ineiit. (Table 20) 90 group,compound mixture of sen- na (2 oz.) was given; to another, 8° castor oil (1;- oz.); to another, 70 magnesium sulphate (1 02.); and 60 to another, calomel (4 gr.). If 50 these experiments proved any- thing, they proved that there is little or no choice among the 30 several purges, with respect to 20 value and efficiency. (See Table ,0 20, page 141.) 0 Diet. The standard routine diet established consisted of rice and gruel (kunji) on the after- noon previous to treatment, and milk on the morning of treat- ment. This diet gave by far the best results. It was adopted wnuour pum WITH puRGE \ only after a series of cases were IFig 4l—Results obtained by treated, with the diet varied. varying diet and omitting initial Some Of ‘the groups m the purge in treating hookworm disease series received PTCVIPUS purga- with chcnopodium. Trial treatment. tion, and some received none. (Table 21) (See Table 21, page 142.) 40 2 E a e g E. i g a E 5 g r: 1: FULL MU THROUGH THE TRUTMENI Z. WLL DIE? ALL THE D" PREVIOUS ro mun-4.4 3“" A Fig. 42.—H00kworm patient, just before being discharged from Kuala Lumpur hospital. Showing good physical con- dition after removal of 604 hookworms Fig. 43.—Severe case of hookworm ane- mia in Chinese youth shortly after admis- sion to hospital. Hookworms expelled, 580; malaria, before admission; spleen, negative; hemoglobin, 5% Fig. 44.—Same case as Fig. 43, after treatment. Note disappearance of edema Fig. 45.—Same case as Fig. convalescence 43, during Fig. 46.—Same case as Fig. 43, after recovery. Hemoglobin, 45% Fig. 47.—Group of former residents of Federated Malay States and Straits Settlements examined at St. John’s quarantine camp, Singapore. Note fine physical condition of coolies re-entering when free of hookworm and malaria CHAPTER VI FINDINGS CONCERNING HOOKWORM INFECTION Work at Port Swettenham. At Port Swettenham the Commis- sion examined the stools of 2,262 persons, of whom 1,736 were men, 384 were women, and 142 were children under 12 years of age. Of this total number examined, 2,188, or 96.7 per cent, were found to be positive for hookworm ova, but inasmuch as stools for second and third examinations were obtained from only 45 of the 74 cases found to be negative, it is perhaps reasonable to assume that the actual percentage was nearer 99 per cent than 96.7 per cent. (See 67 6 Table 22, page 143.) 9° 8 2 Relation between Patient's so Age and Degree of Infection. 10 Examination of the stools of g children under twelve years of :60 age showed clearly that a high :50 rate of infection occurs very 1;: early in life, and that it pro- 5‘0 gresses rapidly until the average E30 percentage for adults 15 reached. These conclusions with reference 2° to the relation between age and lo hookworm infection are based upon the analysis'of results 013- o 2262 ”36 m 142 tamed from expcnments among EXAMINED EMMINED rxmmto mmmto persons of twelve years and ALL under. (The data are presented Egg}? MEN WOMEN “3:5? in Table 23, page 14-4.) SEXCS TWELVE VUIngrablllty 0f Worms to Fig. 48.——Results of examinations Vermicrde 1n Relation to for hookworm disease at Port SPeCies and Sex. The Com- Swettenham. (Table 22) mission found reasons for be- lieving that the various kinds of worms differ in their resistance to a given dose of vermicide—that Necators are less resistant than Ancylostomes, and that males in each species are less resistant than females. This resistance to vermicide was thought to vary with species and sex, increasing as the size of the worm increases. In order that this theory might be verified, a study was made of a series of cases in which chenopodium was used as the vermicide. In the first treatment, the total number of worms removed was 4,296, of which number 3,871, or 90.1 per cent, were Necators and 47 48 INTERNATIONAL HEALTH BOARD 425, or 9.9 per cent, were Ancy- lostomes. Of the 3,871 Neca- tors removed, it was found that 1,897, or 49 per cent, were fe- males and 1,974, or 51 per cent, were males. Of the 425 Amy- lostomes removed, 202, or 47.5 per cent, were females, and 223, or 52.5 per cent, were males. In the second treatment, the total number of worms removed was 217, of which number 108, or 49.8 per cent, were Necators, and 109, or 50.2 per cent, were Ancylostomes, Of the 108 Ne- cators removed, 70, or 64.8 per cent, were females, and 38,0r 35.2 per cent, were males. Of the 109 Ancylostomes removed, 93, or 85.3 per cent, were females, and 16, or 14.7 per cent, were males. Fig. 49.-—Hookworm infection In the third treatment, the rates, by age groups, for children less total number Of worms removed than twelveyearsold. Examinations was 39; of that number, 19, or at Port Swettenham. (Table 23) ; on a o oo 00 o- c z 2 5 ... u. E IA. 0 .5 Z ... U K MJ 0. _~ 000 3-4 YEARS 5- 7 YFARS 48.7 per cent, were Necators, and 20, or 51.3 per 'cent, were Ancylostomes. Of the 19 Neca- tors removed, 16, or 84.2 per cent, were females, and 3, or 15.8 per cent, were males. (SeeTables 24 and 24A, pages 145 and 146.) In the first treatment, as has been stated, slightly over 90 per cent of the worms removed were Necators and only slightly under 10 per cent were Ancylostomes, and after a later treatment the Ancylostomes predominated and szx SEX SEX steadily increased in proportion, while the Necators as steadily nmovto sv «movsoav mm AND diminished in proportion. These FIRST SECOND . . rnmntm murmur data 1nd1cate that the Necators -SPECIES{NECATDRS 55:4 MALE succumb more readily to the first my ANCVLOSTWES- FEMALE treatment, while the results of Fig. 50.—Vulnerability of worms later treatments consist for the in relation to species and sex. most partin the expulsion 0f the (Tables 24 and 24A) more resistant Ancylostomes, PE PCENYAGE REMOVED OF TOTAL WORMS PRESENT FINDINGS CONCERNING HOOKWORM 49 Furthermore, it will be noted that in the first treatment males pre- dominated in both species, whilein later treatments females predom- inated and assumed a greater proportion to the males after each successive treatment. These facts show that the‘females are more resistant to the drug than the males. This fact is further substan- tiated in Table 24A, page 146, which also shows that the Necators are more readily removed than the Ancylostomes, and that in each species the males are more easily removed than the females. Vulnerability of Worms in Relation to Dose of Vermicide. In brief, as a result of their various investigations and experiments, the Commission arrived at the following definite conclusions concern- ing the relationship between the amount of vermicide adminis- tered and the effect which the vermicide has on a given form of worm: ' Lower doses of vermicide, as compared with the higher doses, are more efiective against the less resistant forms of worms. These lower doses are relatively inefiective, however—as compared with the higher doses—against the more resistant forms. The difference between the effects of vermicide on the less resistant and the more resistant forms, respectively, becomes less as the dose is increased. Finally, the larger doses of vermicide are generally of particular use in getting rid of the more resistant forms. It will be seen by reference to Table 25, page 147, that there is considerable difference between the efiects of the higher and the lower doses of vermicide on different classes of worms. In the case of the lower doses the difference in effect upon the less resistant and the more resistant forms, respectively, is seen to be 38.6 per cent, while with the higher doses the difference is 21.3 per cent. In all these experiments, chenopodium was the vermicide used. A series of similar experiments in which thymol was employed, also showed that in the case of the lower CHENOPODIUM doses the difler- ” ence between the effects on the more susceptible and the more resistant worm types, respective- ly, was large— 42.1 percent; with the higher closes the difierence was MALE) FBAALES MALES fEMALLS inconsiderable _ NECATORS mmsTOMEs 2.MILS AND OVER only 4.7 per cent. “. .n- . - These {3‘35 are Fig. 51.—Ei‘lect on Necators and Ancylostomes of clearly revealed 1n varying dosages of thymol and chenopodium. Single Table 26,page 148. trial treatment. (Tables 25 and 26) 4 T HYMOL s s \\ _—-—_— —___—___—. \ / a 3 a s s s s a s s PERCENTAGEOFWORMSREVOVED PERCENTAGE OF WORMS REMMD a s: s 8' 8 3‘ l 50 INTERNATIONAL HEALTH BOARD Relation between Number of Worms Present and Facility with Which They Are Removed. As a result of a number of experiments the Commission was convinced that it is easier to remove a high percentage of worms when there are many worms present than when there are few. All the data were obtained in those cases in which two treatments of the same drug were given. The effect of the first treatment on the total number of worms may be compared with the effect of the second treatment on the much smaller number of worms left after the first treatment. The percentage of worms re- moved in the first treatment, when the number of worms naturally is relatively large, was compared with the percentage of worms removed in the second treat- |00 957 ment, when the number of v, 9° 751 worms is relatively small. Thus, gig 5° when chenopodium was used (.5 :gm mil three times), the first treat- g5 60 ment removed 95.7 per cent of g; 50 the total number of worms :5 to present. The second treatment 3;” removed 77.6 per cent of the E55 20 total number of worms remain- ‘c‘t‘E ‘0 ing after the first treatment. 0 . In the case of all the drugs and mum $5 $9 g3 E; 52* E3 all the methods of treatment g E x “c: 5 x which were employed .and for 32 23 5%; fig i3? which comparative statistics are DRUGS E»: 5; Egg 2g 2?: available, the combined figures mo 3% 3:; gig £5 5?; indicate a similar disparity. DOSES '- 2 83 8 a "‘ When thetotal number of worms Elf-Egg THYMOL present was 5,636, the first ”WM treatment removed, on the av- .FIRSI TREAIMENI WSKOND TREATMENT erage, 823 per cent; and when Fig. 52.—Difficulty 10f expelling the total number amountedonly worms when number harbored is to 997, the percentage removed small. (Table 27) by the second treatmentwas only 37.3. It was therefore perfectly clear that the percentage of worms removed in each case was greater when the number of worms was large than when it was small. (See Table 27, page 149.) Regarding the comparison of the results of the first and second treatments, with the same dose, of the same drug, on the same cases, certain objections might be raised. For example, it might be said that there may have been a difference in the resistance of the worms in the first treatment; or that the high percentage of worms removed may have been due to the removal of the less resistant worms, while, on the other hand, in the second treatment, the percentage may have been lower because the drug was acting on the more resistant worms which remained. That this is not the true explanation may be seen FINDINGS CONCERNING HOOKWORM 51 by noting the efiect, on the different cases, of treatment with various drugs, and by comparing these results in the 56 cases in which the average number of worms per case was less than 10, with results in the 16 cases in which the average number of worms was more than 50. It becomes evident from such a comparison that in those cases with the number of worms over 50 (in which the average number of worms was 106) the percentage of worms removed (i. e. 87.5) was higher than the percentage (i. e. 80.0) in cases in which the worms were fewer than lO—an average of 4.5 worms per case. Work at District Hospital at Kuala Lumpur. For a period of five consecutive months, the Commission worked in the District Hospital at Kuala Lumpur. During this period 1,300 Chinese and 650 Tamils were admitted. Post-mortem examinations were made on 103, or 40 per cent, of the total number of fatal cases. These examinations revealed 35 types of disease. When the total num- ber of deaths due to malaria was compared with the total number of deaths due to hookworm disease, it was found that there were five times as many due to the former as to the latter, and that there were 2.3 times more deaths from malaria among the Tamils than among the Chinese. In the sectioning of the bodies, the intestinal tracts were care- fully searched for helminths. Spleen and marrow samples were examined for malaria plasmodia or pigment, and tissues were sec- tioned for microscopic diagnosis. The analyses of the post—mortem cases furnished a good basis for comparing the incidence of various diseases that proved fatal, as they occurred in the two races. The basis for comparison was particularly accurate since the distribu- tion of the races, in the post-mortems and in the cases admitted to the Hospital during the period, corresponded closely with the numbers of the respective races in the population at large in the state of Selangor. Among the various distinct types of disease occurring in the two races, dysentery, malaria, and tuberculosis were the most common; those due to external causes were found to be relatively few in number (7.7 per cent of the total) and were confined to the Chinese. Further investigations at the same Hospital disclosed the fact that whereas the number of Tamils admitted because of severe hookworm infection was disproportionately great, when compared with the num- ber of Chinese, there were no deaths certainly traceable to hookworm infection among them, while among the Chinese there were four deaths attributable to that cause. In other words, while there were 66 Chinese to 34 Tamils constantly present in the hospital throughout the year, there were among the cases of severe anemia admitted to the Commission’s ward, 6 Tamils having over 500 worms, with no deaths, and 5 Chinese having over 500 worms, with a record of 4 deaths out of 5. It would appear from these facts that while Tamils may harbor many worms and may suffer severe anemia, there is no record of mortality. While the Tamils examined were found to 52 INTERNATIONAL HEALTH BOARD harbor almost as many hookworms as the Chinese and while their hemoglobin was nearly as low, none of them died. This difference in the severity of the disease as between the two races may possibly have been due to the fact that the mouth parts of the Ancylostoma duadenale, a species of which the Chinese had the larger proportion, are larger than the mouth parts of the Necator. This anatomical difference would enable the former to inflict more serious wounds in the mucosa, thus causing a greater degree of anemia. (For certain clinical studies see Chapter VII, page 65.) Work at Singapore. At the quarantine camp on St. John's Island, Singapore, research and investigation work was undertaken for much the same purpose as AVERAGE that which actuated operations I00 HEMOGLOB'N at Port Swettenham,except that the coolies were Chinese instead 90 of Tamils. Indians examined at Port Swettenham came, for the most part, from the south- ern districts of India. Most of the Chinese examined at Sin- gapore came from the southern provinces of China. A consid- erable percentage of the Chinese who entered the lMalay Penin- sula at Singapore had a history of previous residence other than China—usually the 'Malay Pen- insula. Of the 304 whose feces were examined microscopically BO 70 60 NUMBER OF HOOKWORMS E m o .1 o o 2 Lu I i... o w o E 2 w E ii' o 0 but who were not treated, 203, or 66.8 per cent, were found m no FORMER arsmmca ommmucmm . . f h k Of - FORMER RESIDENCE omen THAN CHINA POSIUVC 0F 00 worm 0V3- these Chinese immigrants, 88 were treated for hookworm in— fection. Of the 88, as many as 60 had no previous residence other than China, and the former residence ofimost of the remaining 28 was the Malay Peninsula. The newcomers also proved to harbor a larger average number of hookworms than those who had been longer in the Malay Penin- sula. That is, there were 31.5 worms per individual among the 60 persons who had resided previously only in China, as against the 20 worms per person among the 28 who had had a former resi- dence other than China. The average hemoglobin in both groups was found to be practically the same. Of the 88 who were treated, 62 were men, 20 were women, and 6 were children. The percentage of hookworm infection among the men was 90.3, among the women 85, and among the children 83.3. The gross percentage of hookworm Fig. S3.—Average hemoglobin and average number of hookworms harbored by eighty-eight Chinese treated at Singapore. (Table 28) FINDINGS CONCERNING HOOKWORM 53 infection among men, women, and children was 88.6. The average hemoglobin percentage among the men was 77.5, among the women 65.5, and among the children 79.5. As to both hookworm infection and average hemoglobin, practically the same percentages were found among the immigrants who were treated at Singapore as among those who were later treated in the Federated Malay States. (See Table 28, page 150.) ' Work in the Fiji Islands. Hookworm infection, it was found, prevailed in the island of Viti Levu (Fiji) to as great an extent as in the Federated Malay States and in Java. In fact, in the adult male Indian and Fijian populations the incidence was found to be 100 per cent. There is no doubt that hookworms were brought into the country by Indian immigrants; but severe infections were also en- countered among the aboriginal inhabitants of the island. In all, 190 cases were examined, including Indians, Fijian half—castes, and Europeans; these cases included both adult males and females, and children. Of this total number, 183, or 96.3 per cent, were found to be infected. Half-castes and European children were found to harbor very few worms, although they run barefooted throughout the year and are thus exposed to infection. European adults were found to be free from hookworm ova—except those who were born in Fiji; these, in all likelihood, had acquired infection during youth or adolescence while going barefooted. (See Table 29, page 151.) Among the indentured coolies who underwent medical inspection and hookworm treatment as well, whenever clinical evidence of anemia existed there was some mild anemia. Only two cases of severe anemia were detected. The free coolies who live out in the flat, wet cane-fields were all heavily infected. On their premises the ground water was high and. the shallow latrines in use were by no means sanitary. Among this class there were cases of anemia of all grades, from severe to mild, and their condition, as exhibited at the time of muster and as recorded by the hemoglobinometer, was distinctly below that of the indentured men. These free coolies are not obliged to submit to medical inspec- tion, and do not receive free hospital treatment. Consequently they had received no hookworm treatment since the expiration of their period of indenture, from five to twenty years before. They were found to be very approachable, and no difficulty was experienced in persuading them to enter the Hospital for thorough treatment. The hookworm campaign now being conducted by the Fiji Medi- cal Department, with the co—operation of the International Health Board, reaches a similar class of free coolies, and should result in considerable improvement in their physical condition. These people are for the most part thrifty farmers on a small scale. Since they are disposed to be exceedingly frugal in eating, it is quite probable that the anemia caused by hookworm infection is intensified in this class by chronic conditions of innutrition. INTERNATIONAL HEALTH BOARD 54 3m czar: .3» .ucchoLTEu .comuaaauuo .83 8 wzmwhoam «1:58 momumnm-Eho>§ooml+m .ME mhmommmv mm m~m_m hzwumum 85“. .Bu .Euzzomszm u>_._.02< FINDINGS CONCERNING HOOKWORM 55 The native population represented by Fijians living in remote dis- tricts, out of contact with Indian sources of hookworm infection, was found to harbor Necator amen'canus and Ancylostoma ceylam’cum (the latter being derived from the dogs). Ancylostoma duodenale was entirely absent. This leads to the conviction that Necator ameriamus is a natural parasite of the Fijians, and that very likely Polynesians as well as Melanesians will be found to harbor this species exclusively, except in places where the people may be living in contact with Asiatics who harbor Ancylostoma duodenale. HOOKWORM-SPECIES FORMULA ACCORDING TO RACE The species was always very carefully determined in the case of all the hookworms that were recovered in the course of treatment, and a careful tabulation made of the distribution of species in rep- resentatives of the various races and of the effect of occupation and environment in such distribution. As a result it was found that the proportion of Ancylostomes to Necators varied considerably in the different races. (See Table 30, pages 152 and 153.) Evidence was also found that both occupation and environment tend to limit or to influence the proportion of the species of hookworms with which certain individuals are infected. The distribution and relative num- bers of Ancylostoma duodenale are important on account of their relation to effective and economical treatment. For, since there is. a definite relation between dosage of drug and respective species of worm (more drug being required to dislodge the more resistant Ancy- lostoma duadenale), it is highly desirable to know the Ancylostome formula of the people who are being treated. If this is known it is comparatively simple to adjust the dosage of the drug efficiently and economically, according to the species of worms which are to be removed. It has been found convenient to express the hookworm- species formula in terms of percentage of Ancylostomes, because, this being the more difficult worm to remove by anthelmintics, such terms indicate in the best manner the degree of necessity of using larger dosages of the vermicide. Malays. At Kampong Bharu, 38 kampong boys were treated. These were found to harbor a total of 2,262 hookworms, of which number 2,257 were Necator americanus, and S were Ancylostomes. Of these 5 Ancylostomes, 2 were A. ceylam'cum and 3 were A. duodenale. It will thus be seen that the percentage of Ancylostomes among these boys was only 0.22. The boys of this kampong, so far as their cus- toms indicate, probably re-infect one another, for they are not to any extent subject to infection by Chinese, Tamils, or others, in- asmuch as they live within their own kampongs. The Malay kampong at Ulu Gombak yielded very much the same results. At the kampong 39 boys were treated, and from them a 56 INTERNATIONAL HEALTH BOARD total of 1,559 hookworms were recovered, of which number 1,546 were Necator americanus and 13 were Ancylostomes. Of these 13 Ancylostomes, 6 were A. ceylanicum and 7 were A. duadenale. It will thus be seen that the percentage of Ancylostomes among these boys was 0.8. It is also noteworthy that nearly one-half the the Ancylostomes harbored were A. ceylanicum; this species, while comprising about 60 per cent of the hookworms found in the dogs of Kuala Lumpur, was only rarely found in adult Chinese or Tamils. The adult Malays were easily classed in three distinct groups. In the first group, consisting of Malays principally in the Malay Penin- sula, there were 16 persons with a total of 1,138 hookworms, of which number 1,128 were Necator americanus and 10 were A. duo- denale. The percentage of Ancylostomes in the first group was therefore 0.9 In the second group, consisting of Malays principally from Java, there were 12 persons with a total of 1,757 worms, of which number 1,711 were Necatar amen‘canus and 46 were A. duodenale. The percentage of Ancylostomes in this second group was therefore 2.6. In the third group, consisting of Malays principally from Sumatra, there were 28 persons, with a total of 2,746 hookworms, of which number 58 were Ancylostomes, including 7 that were A. ceylam'cum. The percentage of Ancylostomes in this third group was therefore 2.1. Chinese. The Chinese were found to fall into two groups. The persons in the first group consisted principally of those who came to the Federated Malay States, usually as adults, from the southern provinces of China. To a considerable extent their worm-species formula must therefore represent the infection received in China. Even after these people had spent a number of years in the Federated Malay States, their habits and their superior numbers would, as a rule, lead to their acquiring re-infection from one another rather than from other races. It may be assumed that the worm-species of the sinkehs, or newcomers from China, would give the proportion of the species as it exists in the people from the southern provinces of China. Forty-six sinkehs were treated at the quarantine camp at St. John's Island, Singapore. From them 1,241 worms were obtained, of which number 420 were A. duadenale and 821 were N. amen'ca- nus. Thus the gross percentage of Ancylostomes was 33.8. There were 10 cases of purely Necator infections in this group, which harbored a total of 148 worms. 0f the whole group, 36.9 per cent fell within the formula. Among the cases treated at the District Hospital at Kuala Lumpur there were 79 Chinese, who yielded 5,191 hookworms, of which number 1,994 were A. duodenale and 3,197 were Necator amen'canus. The percentage of Ancylostomes in this group was 38.4. It is inter- esting to observe that there were 12 cases in this group with infec- tions from Necalor americanus, and 37 other cases whose percentage of Ancylostomes was below the apparent average for the whole group. The men of this group had lived in the Federated Malay States for FINDINGS CONCERNING HOOKWORM 57 varying periods up to twenty years. It is entirely possible that they represented to some extent examples of infections acquired from other races. The soil and climate of the Federated Malay States did not seem inimical to the larvae of A. duodenale, for the group consisted of 33 examples of men who were infected with this species, and who had lived in the country from 10 to 20 years. Therefore, they had undoubtedly acquired the infection during the term of their residence. ' Straits-born Chinese. Only two cases of Straits-born Chinese were treated. Nevertheless, the results found were significant, for the species formula is that of the natives of the country, and not that of the Chinese. These two men were hospital dressers, born in Malacca. One of the two cases represents the first generation, the other the second generation, born in the country. On treatment, one yielded 42 Necators and the other yielded 30 Necators. Ancylos- tomes were not obtained from either. The percentage of Ancylos- tomes, therefore, in these two Straits-born Chinese was nil. Tamils and South Indians. The natives of South India— Tamils, Telegus, and Malabaris—have a worm-species formula approaching very closely that of the Malays of the Federated Malay States. . During the time that treatments were being carried out at the Port Swettenham quarantine camp, 10,455 hookworms were recovered, of which number 312 were A. duodenale and 10,143 (the remainder) were N. americanus. The percentage of Ancylostomes, therefore, was 2.9 among Tamils entering the country. A number of these 10,455 worms were obtained from three treatment squads. In these treatments, 4,363 worms were obtained, of which number 89 were A. duodenale and 4,274 (the remainder) were N. amen'canus. The percentage of Ancylostomes, therefore, in this sub-group, was 2.0. This percentage probably represents the proportion of the two species of hookworms among the natives of southern India. During the early part of 1916, a number of Malabaris from South India who had lived in the Federated Malay States but a few months, were treated. Altogether there were 25 cases, yielding 3,491 worms, of which number 30 were A. duodenale and 3,461 (the remainder) N. americanus. The percentage of Ancylostomes, therefore, among these Malabaris was 0.86. The treated cases at the District Hospital included 118 Tamils who had resided in the Federated Malay States for varying periods up to twenty years. From these Tamils, 12,806 worms were obtained, of which number 658 were A. duodenale and 12,148 (the remainder) N. americanus. The percentage of Ancylostomes, therefore, was 5.1. This percentage probably represents the modicum of infection suffered by Tamil residents in the Federated Malay States, where there is a large but scattered Chinese population with its high Ancylostome index. The comparison of the species percentage composition of newly arrived Tamils, or Malabaris, with those Tamils who transported 58 INTERNATIONAL HEALTH BOARD and buried night soil obtained from the city of Kuala Lumpur (which has a large Chinese population), furnishes further evidence of the infection of Tamils from Chinese sources. Fifty-seven night- soil coolies (men, women, and children) were treated. These coolies had followed their vocation for periods varying up to eleven years. The total number of worms harbored by this group of 57 persons was 7,259, of which number 806 were A. duodenale and 6,453 (the remainder) were N. americanus. The percentage of Ancylostomes, therefore, in this group of coolies, was 11.1. Undoubtedly this percentage represents the infection derived from Chinese sources by the handling of night soil. This group of coolies was compared with the group of Tamil coolies engaged in road- repairing. Those in the latter group were not exposed to hook- worm infection in the same degree as were the night-soil coolies. A group of 35 road coolies were treated. This group was made up of men, women, and youths. None in the group had ever worked as a night-soil coolie. They had all lived in the Federated Malay States for periods varying up to fifteen years, sometimes employed on estates and sometimes on public works. As the result of treatment they yielded 2,870 worms, of which number 59 were A. duodenale and 2,811 (the remainder) N. americanus. In this coolie group, whose members were not especially exposed to infection from Chinese sources, and in whom the South Indian formula was retained, the percentage of Ancylostomes was 2.0. People of Northern India. It appears that the people of north- ern India have a species percentage composition differing from that of the people of southern India. There are relatively few people from northern India in the Federated Malay States, but the people of that region are represented in the Commission's series of Sikhs and Mohammedan police from the Punjab. These men, however, had lived in the Federated Malay States for several years and the Ancylostome index natural to them in their own country cannot be positively ascertained. Thirteen Sikhs were treated in Hospital No. 2. All who had lived in the Federated Malay States for periods of 10 years or over, or who had worked on estates, were excluded. It was found that the 7 remaining men harbored only 41 hookworms, of which number 21 were A. duodenale and 20 (the remainder) N. americanus. The percentage of Ancylostomes, therefore, in this group was 51.2. On the other hand, if we take those who had lived for periods of 10 years or more in the Federated Malay States, or who had been employed on estates (where there would be more opportunity for acquiring infection by Necators), we have 3 cases harboring a total of 39 worms, of which number 5 were A. duodenale and 34 (the re- mainder) N. americanus. The percentage of Ancylostomes, there- fore, in this group, was 12.5. In Hospital No. 1, 8 Sikhs were treated. These may be separated into 2 groups, the first consist- ing of those who had lived in the Federated Malay States 10 years FINDINGS CONCERNING HOOKWORM 59 or more, and the second group consisting of those who had lived in the Federated Malay States less than that time. Investigation re- vealed the fact that in the first group there were 6 cases, harboring a total of 83 worms, of which number 65 were A. duodenale and 18 (the remainder) N. americanus. The percentage of Ancylostomes, therefore, in this group was 78.3. In the second group 2 cases were found harboring a total of 139 worms, of which number 6 were A. duodenale and 133 (the remainder) N. ameficanus. The percentage of Ancylostomes, therefore, in this group was 4.3. The conclusion which may be drawn from these figures is that the Ancylostome index of the people of northern India, at about 30 degrees N. latitude, would be found to be as high as that of the people in southern China, living at 23 degrees N. latitude. Japanese. A group of four Japanese prostitutes who had been in the Federated Malay States three years or less, were treated. These 4 women were found to harbor 61 worms, of which number 19 were A. duodenale and 42 (the remainder) N. amen'canus. The percentage of Ancylostomes, therefore, in this group was 31.1. The indications are that the Japanese have, in common with the races farther north, a higher Ancylostome index than the natives of the Federated Malay States. Europeans. Only three of the six Europeans (all planters) from whom hookworms were obtained upon treatment, had certainly acquired their infection in the Federated Malay States. The other three may have acquired it there, but inasmuch as they had lived in other tropical countries before coming to that country, it is perfectly possible that they may have acquired their infection elsewhere. Of the 3 men who had never lived in places other than the Federated Malay States where hookworm infection was known to occur, one harbored 8 worms, all of which were A. duodenale; another harbored 9 worms, 2 of which were A. duodenale; and the third man harbored 20 worms, 1 of which was A. duodenale. It is highly probable that the planters who become infected in the Federated Malay States derive their infection from mixed sources. While it is comparatively easy to determine whether or not a group of Tamils have become infected from Chinese sources, it is extremely difficult to say whether Chinese old residents are being infected by Tamils or Malays. Recently arrived Tamils and Malays rarely harbored A. duodenale, or else harbored these worms in very small numbers. 0n the other hand, it is known that the Chinese harbored considerable numbers of N. americanus. Further- more, about 15 per cent of the sinkehs, or newcomers, examined at St. John’s Island, showed infection according to the Tamil or Malay formula; that is to say, among other worms a very large majority of Necators was found. There is, however, always some room for doubt in the case of a Chinese declaring himself a sinkeh; he may be a former resident who is disinclined to admit the fact. 60 INTERNATIONAL HEALTH BOARD Javanese. In Java there were geographical and racial differences in the proportion of the species of worms present. For example, in the kampongs of Batavia a total of 2,935 hookworms was obtained, of which number 26 were found to be A. duodenale and 2,909 (the remainder) N. americanus. In this group, the percentage of Ancy- lostomes was, therefore, 0.8. The same difference was found in Preanger. At Endil, 25 natives were treated and from them 1,275 worms were obtained, only 2 of which were Ancylostomes; both of these were A. ceylanicum. In West Java, in the three places visited, the proportion of Ancylostomes was found to be very small indeed. The worm formula, in fact, resembled that of the South Indians, the Sumatrans, or the natives of the Federated Malay States. In Mid-Java, the Ancylostomes appeared in larger numbers in every kampong and were evenly distributed throughout the popula- tion. At Gebongelir, Mid-Java, 50 natives were treated and from them 2,339 worms were obtained, of which 308 were A. duodenale and 2,031 (the remainder) N. americanus. The percentage of Ancylos- tomes in this group was, therefore, 13.1. At Kalimaro, which is one and one—half miles away, 24- persons upon treatment yielded 5,140 worms, 322 of which were A. duodenale and 4,818 (the remain- der) N. amen'canus. The percentage of Ancylostomes was, there- fore, 6.2. At Kebasekan, the 25 persons who were treated yielded a total of 4,082 worms, of which 219 were A. duodenale and 3,863 (the remainder) N. amen'canus. Therefore, in this kampong, the percentage of Ancylostomes was 5.4. At Krakal-Karangsari, 28 natives were treated and from them 10,861 worms were obtained. Of this number, 770 were A. duodenale and 10,091 (the remainder) N. americanus. The percentage of Ancylostomes was, therefore, 7.0. Thus, a well-marked difference was noted between the Ancylos- tome index of the Malays of Batavia and the Sudanese of Preanger on the one hand, with their universally low index, and the Javanese of Mid-Java on the other hand, with their uniformly higher index. The prisoners at the Batavia jail were treated and examined for evidences along these lines. These prisoners, in spite of the fact that there seemed to be no possibility of acquiring new hookworm infections in the jail, showed an Ancylostome percentage of 9.2 (with a total worm count of 8,633), while the people in the neighboring kampong—even within a stone's throw of the jail—had a low Ancy- lostome index. It would appear from this that their infection must have been acquired elsewhere, and, as a matter of fact, this theory was confirmed by separating the men into groups according to the particular part of the Netherlands Indies from which they came. For example, there were 9prisoners who gave their place of residence as MidoJava or East Java, whose total worm count was 755, of which 57 were A. duodenale. In other words, they showed an Ancylostome percentage of 7.5. On the other hand, 2 persons who gave their place of residence as Batavia or Preanger showed an Ancylostome percentage of only 0.76, for out of a total of 130 worms yielded by these 2 persons, only one was A. duodenale. Fig. 55.—Two cases of hookworm anemia in Mid-Java. The younger man was an imbecile and total worm count was not obtained. The other case harbored 843 hook- worms. Spleen and plasmodia, negative; hemoglobins were 13% and 10% respectively Fig. 56—Cases of hookworm anemia and malarial anemia contrasted. The Tamil harbored 1,063 hookworms; hem— oglobin was 5-10% and spleen was negative. The Chinese harbored only 82 hookworms; hemoglobin was 30% and spleen was enlarged a hand’s breadth FINDINGS CONCERNING HOOKVVORM 63 Sumatrans. Regarding the worm formulae of the prisoners coming from‘Sumatra and from the other islands in the Netherlands Indies, an equally well-marked difference was noted between the formula of the Malays from Sumatra, for example, and the formula of the natives of the islands of Madura, Bali, Lombok, and Timor. Madura is a small island almost touching the eastern end of Java. The inhabitants have colonized in East Java and are becoming assimilated. There were 16 prisoners from Madura, from Whom 1,263 worms were obtained, of which 173 were A. duadenale,‘ thus the Ancylostome percentage was 13.7. The Ancylostome index of the natives found on the islands of Bali, Lombok, and Timor resembles that of the people of Mid-Java and East Java more closely than it does that of the people of West Java. Bali, with 5 cases having a total worm count of 348, gave an Ancylostome percentage of 4.0. Lombok, with 4 cases having a total worm count of 479, gave an Ancylostome index of 3.3; Timor, with 4 cases having a total worm count of 100, gave an Ancylostome index of 62.0 per cent. Among those examined there were from Sumatra 12 cases, which fell into the group corresponding to West Java and Malaya. The total worm count of these 12 cases was 919, and of that total only 7 worms were A. duodenale; the Ancylostome percentage was there- fore 0.9. There were two cases from Sumatra, with formulae resembling those of the Chinese. One of these two men was qdestioned at the time of examination, and was found to be a Madras Tamil employed as a cart—driver on a tobacco estate, where he lived for five years close to the Chinese lines. These 2 cases yielded 38 worms, of which 25 were A. duodenale; hence the percentage of Ancylostomes was 65.0. These data, of course, would seem to point to the fact that the men were infected from Chinese sources. From Celebes there were 4 persons with a total worm count of 523; all of the worms were Necators. This means, of course, that the Ancylostome index was nil. The island of Celebes lies to the north, and is not a part of the chain of which Mid-Java, Madura, Bali, Lombok, and Timor are all units. The Chinese treated in the jail were of three groups. In the first group—Chinese who were born in China but who had lived in Sumatra, where there was a low Ancylostome index—there were 13 cases with 838 worms, of which 255 were A. duodenale. The percentage of Ancylostomes, therefore, in this group was 30.4, which is a Chinese formula. In the second group—Chinese who were born in Mid-Java—there was only one case, with a total count of 57 worms, of which 11 were A. duodenale. The percentage of Ancylos- tomes in this group was, therefore, 19.3, which is a Mid-Java formula. In the third group—Chinese who were born in West Java—there was also but one case, whose worm count was 123, and only one worm was A. duadenale. The percentage of Ancylostomes was, therefore, only 0.8, which is a West Java formula. 64 INTERNATIONAL HEALTH BOARD It does not seem likely that the presence of A. duodenale in Mid- Java or East Java and in the eastern chain of islands, is at all due to the presence of Chinese, for the native stock greatly outnumbers them; moreover, the Java-born Chinese appear to evidence the formula of the natives of the 10cality, rather than the formula of the Chinese born in China. It is quite possible that the Ancylostome index afiords a clue to the ethnic origin or composition of the natives of Malaya, Java, and the other islands of the Netherlands Indies, and that a high Ancylos- tome formula indicates a large admixture of ethnic stocks from northern India or elsewhere. It will be remembered that centuries ago a considerable Hindu civilization flourished in Mid—Java, East Java, and Bali. Many of the Malays of the Federated Malay States claim Sumatra as their ancient home—indeed, it is often stated that it is the ancient home of the race—and the Ancylostome formulae of the natives of the two countries appear to be identical. (See Table 30, page 152.) CHAPTER VII FINDINGS CONCERNING MALARIA Post-mortem Data. At the District Hospital at Kuala Lumpur a number of post—mortem examinations were made. It was found that the deaths due to malaria could be classified in two groups. The first group was made up of those who suffered from acute pernicious malaria, in which cases myriads of plasmodia were found in the spleen, bone-marrow, or brain. There were 4 such cases, 3 of them Tamils and 1 a Chinese. This proportion corresponds with the distribution of these races on estates, and appears to represent the degree of exposure to infection from malaria to which they were subjected. The second group consisted of those who suffered from chronic cachexia as the result of neglected, untreated malaria. While the individual cases of this group were not overwhelmed by large num- bers of plasmodia, their blood-forming organs were gradually over- powered by small, but repeated dosages of the poison. Physical debility, incapacity for work, dysentery, malnutrition, and semi- starvation all contributed to hasten the development of a cachexia, and thus to bring about the coolie's death. Inasmuch as cachexia occurs irrespective of the presence or absence of hookworms, it is probably safe to assume that these cases of the disease were due to malaria. Eleven cases of anemia were found to fall in this group. The number of worms recovered was not suffi- cient to cause any measurable degree of anemia, and it may therefore be assumed that the cause of death was long-contin— ued exposure to malaria. From these post-mortem examina- tions, it would appear that hookworm disease was not a “‘55 1°"°°""°R"°V‘ cause of death among the Tamils in the series. p Z u U a u a Fig. 57.—Results of fecal examina- tions for hookworm disease and Rho“ and Feces Examin- blood examinations for malaria. ations. Blood examinations District Hospital at Kuala Lumpur. were made on 588 patients at By race. (Table 31) 65 66 INTERNATIONAL HEALTH BOARD the District Hospital at Kuala T Lumpur, and 35.4 per cent were w found positive for malaria para- sites. Feces examinations were made on 524 patients and 76.2 per cent were found positive for so— hookworm ova. If the first stool specimen was found negative, a second specimen was obtained in a few days for another examina- tion. Both blood and feces ex- aminations were made for 522 of the total 588, including Chinese, '0 Tamils, and Bengalese: 35.2 per 0 cent preved to be positive for ma- POSITIVE NEGATIVE POSITIVE NEGATIVE laria, and 75.7 per cent proved to HOOKWORM MALARI A bepositivefor hookworm disease. DISEASE _ POSITIVE T0 80TH HOOKWN DISEASE AND ”MARIA Of the 648 per cent Who were WNEUIIVE TOBOTI’I HOOKWORI‘I DISEASENID MALARIA FOSIIIVE l0 "DONOR“ DISIJISENEGNIVE TO MARIA POSITIVE T0 ”ALARM NEGATIVE T0 HWW DISEASE 3 75] 70~ 30 ‘° .552 PERC ENTACE 30 negative for malaria, 77.5 per cent were positive for hookworm disease- 0* .036 75~7 Per cent Fig. 58.—Rates of malaria and who were positive for hookworm hookworm infection among Chi- disease, 33.7 per cent were posi- nese, Tamil, and Bengalese pa- tients; 522 cases at District Hos- pital, Kuala Lumpur. (Table 32) tive for malaria also. Of the 24.3 per cent who were negative for hookworm disease, 40.2 per cent were positive for malaria. It is thus evident that there was a high degree of malaria infec- tion among those who came for treatment. (See Tables 31 and 32, pages 154 and 155.) Spleen Examinations at Port Swettenham. At Port Swettenham, 2,261 coolies were examined with reference to the 2261 437 possible presence or absence of spleen enlargement; a total of 130, or 5.7 per cent, enlarged spleens werefound. Amongthe 1,726 persons who had never before been out of India, 60, or 3.5 per cent, had enlarged PERCENTAGE WITH ENLARGED SPLEENS FEDERATED OTHER mUNTRIES Fig. 59.—Correlation between in- tensity of enlarged spleens and pre- viousresidence in malarious locality. spleens. Among the 437 Who Spleen examinations at Port Swet— had a record 0‘ PFCVIOUS ”Si" tenham. (Table 33) dence in the Federated Malay FINDINGS CONCERNING MALARIA 67 States, 59, or 13.5 per cent, had enlarged spleens. (See Table 33, page 156.) The size of the spleen was classified as being negative, palpable, one finger’s breadth below the ribs, two fingers' breadth below the ribs, three fingers’ breadth below the ribs, one hand’s breadth below the ribs, or to the pelvis. Additional examination of 150 children under 12 years of age proved that only 5 had enlarged spleens; thus the spleen rate among these children was 3.3 per cent. Blood Examinations at Port Swettenham. Immigrants at Port Swettenham were examined for evidence of plasmodia in the blood. In a series of cases examined in 1915, the percentage of those found positive was 5.2 among the 189 who had never before been out of India, and 9.7 among those who had a history of previous residence in the Federated Malay States. Among a series of cases examined in 1916 the parasite rate was found to be 3.4- per cent among those who had never been out of India before, and 12.5 per cent among those who had a history of previous residence in the Fed- erated Malay States. The dif- ference between the percentage in the 1916 series and that in the 1915 series is small, the percent- age in the 1916 series being but 2 per cent less than that in the 1915 series. This difference may be due, at least in part, to a selection of cases with enlarged spleens in the 1915 series. (See Table 34, page 157.) Blood Examinations in Malaya. In the course of the Commission’s work, altogether 2,712 cases were examined for plasmodia in the blood: 677 at the quarantine camps at Port Swettenham and Singapore; 533 _ . at two jails; 168 at six schools; F‘g- (SQ—Correlation between 661 at hospitals: 404 on 14 fié‘é‘i;§l§i?§§m§ifil’fiig’fii “1pr estates; 162 at a tin patierit. Blood examinations at $323132;ng 033E322: PortSwettenham. 1915. (Table 34) public works department. Of this total number (i. e. 2,712), 463, or 17.1 per cent, were found positive for malaria parasites in the blood. Of the 463 mentioned, 82 showed subtertian rings alone; 56 showed subtertian rings and crescents; 74 showed crescents alone; 128 showed benign tertian alone; 109 showed quartan alone; 7 showed benign tertian and crescents; 3 showed quartan and crescents; 2 showed sub- 5 ._ z W L) K K 5. G o x U) 4 _—l A. 5 “5 < I 0 v— “I Z. 2: § 536 124 |89 Z3 IOO 236 NO 226 INDIA ONLY MALARI A SPLENIC PLASMODIA AGE TQTAL EXAMlNED 68 tertian and benign tertian; and 1 showed benign tertian and quartan. The decided preponderance of subtertian rings in the type of para site was very noticeable. The large number of hospital cases tended to increase the malaria incidence of the total, but an examination of the separate groups showed that malaria was present, to a con- siderable degree, in cases not seeking hospital aid. Malaria Survey at Port Swettbnham. A comparison of the hemoglobin percentage of those who had never left India before, with those who had, as shown in Table 35, page 159, would seem to indicate that the degree of anemia found was due to residence in malarious countries—in other words, that the anemia found was malarial in origin. A malaria survey was conducted in the neighborhood of the quar- antine camp at Port Swettenham. Very few adult anophelines were caught in the camp, and of those that were caught only compara- tively few were found within a radius of one-half mile, except in one particular locality. Some 150 females caught were dis- sected and, of these, two were found with sporozoites in the salivary glands. . The area between the nearest large breeding-place and the camp was inhabited, and the houses may have acted as a screen to the camp itself. At any rate' as far as A. ludlowi and A. 7055i were concerned, two other large breeding-places of these species were located in the immediate vicinity of houses INTERNATIONAL HEALTH BOARD um 00 PER CENT V3 2 w “J _. n. U) c: U u: § z IA-I :: t 2 v: u] g 6 $333. as 5?...5? 8 s a NO) _ N N 2225 [30 N m ‘0- tv no r~ N *_“"" Fig. 61.-—Correlation between hemoglobin rate and incidence of en- larged spleen. Examined for malaria at Port Swettenham. (Table 36) within the coolie lines. These probably proved a greater at- traction to the anophelines than the camp, which was situated about half a mile away. The main breeding-place for A. um— brosus was found to be located about one and one-half miles from the camp at Port Swettenham, and many houses intervened between the breeding-place‘and the camp. During the period of the malaria survey, 215 adult A. umbrosus, 36 A. 1055i, 42 A. ludlowi, and 3 A. kochz' were caught within a radius of approximately one-half mile from the camp. Within a radius of one mile from the camp, in the houses located in the different sec- tions of Port Swettenham, 1,068 A. umbrosus, 176 A. rosn’, 74 A. ludlowi, 63 A. kochi, 1 A. tessellatus, and 1 A. kawari were found. FINDINGS CONCERNING MALARIA 69 From the evidence obtained during the survey it may be concluded that the possibility of malaria infection of coolies in the camp at Port Swettenham cannot be excluded. A comparison of the blood examination of groups with different lengths of residence in the camp, indicates that infection was taking place to a very small extent, if atall, at the time of the examination (August, 1916). The coolies who were examined at Port Swettenham during the period from Sep- tember to December, 1915, showed little or no malaria when they were subsequently re-examined on healthful estates. From that fact it is safe to conclude that malaria infection of coolies at the camp at Port Swettenham occurred in a very small degree, if at all, during periods of examination of coolies there. The fairly close relationship between the percentage of palpable spleens and the amount of anemia, indicated by the percentage of hemoglobin found, is shown in Table 36, page 160. Malaria Survey on Estates. A malaria survey of each estate visited and of its immediate environment, was made during the course of investigations. One estate would be found to be located on a flat coastal plain with no uncleared jungles, no springs, and no hillside seepage, and therefore properly to be described as non-malarious. Another estate would be found to be decidedly hilly, with many springs and streams flowing from the hillsides. On such an estate, the seepage would create swamps and other propagation areas for mosquitoes. A locality like this would be properly described as a most malarious estate. In the course of the malaria survey such anophelines as were known carriers of malaria (e. g. An- opheles maculatus) were caught, and the females were dissected for evidence of infection. The malaria surveys on these several estates went to show that those in the interior, of a hilly nature like that described, where there was an absence of anti-malaria measures, were more malarious than those on the level coastal plains. The latter had been cleared of jungles and drained, and were therefore relatively free from malaria—except where prop- agation areas were found for A. ludlowi, which is a known carrier. A group of 9 children on one estate was especially examined for hookworm disease, and it was found that among them 4.5 times as many worms were harbored in cases with as low an average of hemo- globin as 42.9 per cent as in cases which showed as high an average as 82.2 per cent. These cases, it should be explained, were found on the flatland estates where the incidence of malaria is low. All the surveys, investigations, and treatments on the fourteen estates visited were made during the year 1916. These several es- tates were visited from 30 to 40 weeks after the examinations at Port Swettenham or at Singapore. The estates selected were, as has already been explained, those on which were to be found the coolies that had been either examined or treated at one of those ports. As many as possible of these coolies were re-examined for 70 INTERNATIONAL HEALTH BOARD evidence of exposure to malaria and for indications of changes in hemoglobin. . It was discovered that there was an average gain of 3.2 per cent hemoglobin among 234 coolies who entered the ports free from ma- laria but infected with hookworm disease. There was an average gain of 8.4 per cent in 162 cases that contracted no malaria after entering the Federated Malay States, and an average loss of 8.6 per cent in the 72 cases that did contract it. A combination of these last two figures would indicate that residence in the Federated Malay States should normally result in a gain of 17 per cent in the hemoglobin content. Normal expectancy of gain is probably attributable to the better wages and the better food which the workers enjoy in the country of their temporary adoption. It was perfectly clear that the tendency to gain hemoglobin was much afiected by malaria. As between those who did, and those who did not, contract malaria during their period of residence in the Federated Malay States, there was a difference, in the average gain, of 17 per cent hemoglobin per case. As between those who did, and those who did not, contract hookworm infection during their residence in the Federated Malay States, there was a difference of 16.8 per cent average gain. Fig. 62.——Gain or loss in hemo— Tables 37, 38, 39, and 40, globin aftenresidence on estates. pages 161 to 164, show the re- Re-examination, on estates, 0f sults of the findings of coolie coolies found free of malaria but re-examinations on the several norms: DECREASE. infected with hookworm disease on - arrival at Port Swettenham. (Tables estates. iTable 37 gives the 37 and 38) changes in hemoglobin (for all the estates that were visited) shown by coolies who were free from malaria but infected with hookworm disease on arrival at Port Swettenham. First, as to the cases with evidence of malaria after arrival, Table 37 indicates that the 28 cases treated for hookworm at Port Swetten- ham showed an average loss of 5.7 per cent hemoglobin. The aver- age loss of the 44 cases not treated at Port Swettenham was 10.4 per cent hemoglobin; the average loss for the total of 72 cases, irre- spective of treatment, was 8.6 per cent hemoglobin. Therefore, the benefit due to treatment for hookworm in the malaria cases was Fig. 63.—Estate children. Free of malaria (spleen and plasmodia negative) but With heavy hookworm infection. Although their physical appearance is good, their anemia is severe. Average number of hookworms harbored, 191, ranging from 27 to 402; average hemoglobin, 43, ranging from 12 to 66 Fig. 64.—Treatment squad in Sawah Besar (Batavia). Hookworm incidence, 80%; aver- age worms, 19.6. These vigorous and more lightly infected town dwellers do not require treatment so urgently as the debilitated and more heavily infected agricultural populations FINDINGS CONCERNING MALARIA 73 4.7 per cent, or the difference between the loss shown by the treated Cases and that shown by the cases that were not treated. Next, concerning the cases with no evidence of malaria after arrival, the table indicates that the 41 cases treated at Port Swet- tenham showed an average gain of 15.2 per cent hemoglobin. . The average gain of the 121 cases not treated at Port Swetten- ham was 6 per cent hemoglobin; the average gain for the total of 162 cases, irrespective of treatment, was 8.4 per cent hemoglobin. Therefore, the benefit due to treatment in the non-malaria cases was 9.2 per cent, or the difference between the gain shown by the treated cases and that shown by the cases that were not treated. As for the gain due to treatment, irrespective of malaria, Table 37 indicates that the 69 cases treated at Port Swettenham showed an aver- age gain of 6.7 per cent hemoglobin. The average gain of the 165 cases not treated at Port Swettenham was 1.6 per cent hemoglobin. Therefore, the gain due to treatment was 5.1 per cent hemoglobin. Table 38 gives a detailed account of the changes in hemoglobin, on all the estates that were visited, shown by the 19 coolies Who had evidence of malaria on arrival at Port Swetten- ham. The table indicates that the average 0 gain in hemoglobin of the total of 12 cases m -|'6 showing evidence of malaria on the estates as g 5 well as at Port Swettenham, was 10.6 per cent. g The average gain in hemoglobin of the 7 E cases without evidence of malaria on the z 10 estates, was 16.6 per cent; the average gain of a the 5 cases that were treated at Port Swetten- g ham was 15.8 per cent; the average gain of g ‘5 _|5J the 14 cases that were not treated at Port ‘5; Swettenham was 11.7 per cent. . . 20 . From these data it Will be seen that the 5:3 3m cases with evidence of malaria on arrival at 5!; 5i“: Port Swettenham do not show the loss in hemo- 9 l7) 2 ,S 1 b' h b h ' ' f f >‘“ w “’ go in s own y t e cases arrivmg ree rom Luz gm malaria. On the other hand, the cases that if: I?) do not show evidence of malaria on the estates E E E 5 show a greater rise in hemoglobin than the a: «ng cases that still show evidence of malaria. g: g g There is a slight benefit in treatment demon- F *5 .n‘c‘; strable in this series of cases as well as in the series which was shown to be free from Fig.65.—Gainorloss malaria on arrival at Port Swettenham. in hemoglobin aft“ Table 39 shows what happened with regard to resrdence .0“ estates. the hemoglobins of the twelve cases which were Re—exammation 0f . coolies free of ma- traced to estates, and which were shown to be laria and hookworm free of both malaria and hookworm disease at disease on arrival at Port Swettenham. The figures in the table in- Port Swettenham. dicate that all the cases showed a loss of hemo- (Table 39) 74 INTERNATIONAL HEALTH BOARD globin even when they did not contract malaria. This was proba« bly due to the fact that they became infected with hookworm disease, for the five cases that did not contract malaria went to a flatlands estate where hookworm disease was proved to be an important factor in causing debility. Table 40 is a summary of the gains or losses in hemoglobin, with re- spect to malaria, of all the coolies found on each estate. When all the coolies found on an estate are taken as a single group, and the gross average change in hemoglobin is calculated—irrespective of treatment or of malaria—an important in- dex is obtained showing the rela- tive healthfulness of the estates. In the table, this gross average change in hemoglobin is com- pared with the number of cases showing evidence of malaria, and the estates are arranged in the order of the degree of change in hemoglobin found. The close re- lationship between the change in hemoglobin and the number of cases showing evidence of mala- ria,isaveryimportant indication of the power of malaria as a fac- tor in the production of anemia. INCREASE DECREASE p 2 la! 9 a W x“; E a O .J O O z N 1 5 N i U E Ill > < 2 Malaria in the Java Kam- s‘: pongs: Relation to Hook- pmmnct mum, lNFECTION worm. In the course of the work in Java, the Commission under- , _ , . took to ascertain what corre- Fig' 66.—Re-e{ram1nation of 267 spondence there was, if any, be- ?Ohe? after reswlence on estates. tween malaria infection and the nemia and malaria. (Table 40) number of hookworms harbored. The Java kampongs, or compounds, may be divided into three classes with respect to malaria: (1) those highly malarious, (2) those free, or nearly free, from malaria; and (3) those with a few cases of malaria. Among patients residing in the first class of kampong, the spleen rates were high, while the worm counts were not. In Jaagpad, for exam- ple, the spleen rate was 91.9 (100 in the treatment squad), and the average number of hookworms harbored was 34.4. At Gebon- gelir the spleen rate was 97.0, and the average number of worms harbored was 46.7. At Endil the spleen rate was 87.6, and the average number of worms harbored was 51. In these dessas, or vil- lages, it was apparently impossible to ascertain what influence either infection had on the other (malaria or hookworm) for practically the entire population was infected with both malaria and hookworm disease. Malaria always caused the greater amount of anemia, for the reason that the hookworm infections were usually mild. mnruostomn Imus: - HEMOGLOBIN DECREASE Fig 67.~People of Batavia treated at Kampong Kramat. Spleen rate, 11.4%; plasmodia, negative; hookworm inci- dence, 100(70; average number of worms per individual, 45 Fig. 68.~—Two cases of hookworm infection in the highly malarious Kampong of Jaagpad, Java. The man had 54 worms; hemoglobin, 5%; spleen, 3 fb. below costzal margin; blood contained malignant tertian plasmodia. The girl had 11 worms; hemoglobin, 67%;; spleen, 2 fb. below umbilicus; blood showed polychromasia but no plasmodia at the time Fig. 69.—A prolific breeding place in brackish water for the anophelines which spread malaria in the kampongs 0f Batavia near the sea MALARM mrzcnou 00 JAAG PA D Mal-ff JAIL AT EATAVIA Mam: 66.2 DJIM SATAN 2 KRAMA ' 0 6,600 Meters METERS I 1.4 rRoM SM 2000 ,000 7,000 Fig. 70.—Correlation between incidence of malaria infec- tion and distance from the sea. Spleen rates vary in— versely with the distance FINDINGS CONCERNING MALARIA 77 In Kalimaro, Kebasekan, and Krakal, on the other hand, there was little or no malaria, and the worm counts were high—Kalimaro 197.5 and Kebasekan 168.0 per person. These figures are about three or four times as high as those obtained in the malarious dessas, and the number of persons with palpable or enlarged spleens was too small for the data to afford any basis for an estimate as to the possible influence of one infection on the other. The figures obtained in Batavia kampongs and in the jail, however, perhaps furnish some basis for comparison. The entire city may be regarded as urban, although, as explained elsewhere, the natives , 80 live in their kampongs within 70 the city limits. In the city there is less soil pollution, how- 60 ever, than in the strictly rural districts. Near the sea there is severe malaria, but the incidence diminishes as the distance from the sea increases. It is therefore possible to compare the inci- dence of hookworm infection and of malaria in the four kam- pongs. The figures of such a comparison are shown in Table 41, page 165. It will be seen from this table that there is a considerably larger average number of worms in the group SPLEEN SPLEEN SPLEEN ' With enlarged spleens than i“ NEGATIVE PALPABLE ENLARGED the negative-spleen group. Malaria in Java Jail: Re- Fig. 7l.—Relationship between lation of Worms. Given, as splenic condition and number of positive evidences of malaria, hookworms harbored. Eighty-three the resence of lasmodia in persons treated for hookworm in the geripheral blolbd, enlarged kampongs ofJava. (Table 41) spleens, or both, and as negative evidences the absence of plasmodia, and conditions showing the spleen neither enlarged nor palpable, the treated cases in Penal Institution No. 3 may be divided into the six following groups: Group I—Spleen palpable—Plasmodia present (‘ K‘ 50 40 50 20 IO 0 44 IO 29 CASES CASES CASES AVERAGE NUMBER OF HOOKWORMS HARBORED Group II— enlarged— present Group III— “ palpable— “ absent Group IV—- “ enlarged— ” absent Group V— “ negative— “ present Group VI—- “ negative— ” absent Groups I, II, III, IV, and V contain all the cases with positive evi— dences of malaria at the time of examination. Group VI contains 78 INTERNATIONAL HEALTH BOARD the cases with negative evidences—that is, evidences showing active malaria to be absent—for it is understood that all the prisoners are constantly exposed to severe malaria infection. In the aggregate, however, only a certain limited number of men at any given time exhibit evidences of active malaria~plasmodia, fever, and spleen enlargement. Reference to Table 42, page 166, will show that the average hemo- globin for the malarial groups was 66.9 per cent, and for the non~ malarial group 81.2 per cent, while the average number of worms in » . the former groups was 98.4 and in the latter group 54.8. Thus 90 it would appear that in this jail 80 ' there was a correlation between . the presence of malaria and the 70 number of worms. 50 It must be remembered that 5 the men were constantly exposed 0 to malaria infection and were 40 in astate of inconstant flux with 30 regard to it—men suffering from the disease one month being apparently free from it the '0 next. This condition was dem— onstrated at the jail by the con— 40 CASES 48 CASES dition of men whose spleen and MALARIA IA blood were negative, but who GROUP GROUP succumbed to malaria Within a few days after admission to the .AVERAGE HEMOGLOBIN6>ER CENT) ward, and also by the diminu- HOOKWORMS HARBOREDQVERAGE tion in size of spleens in malaria cases at the time of re-examina- 20 Fig. 72.——-Correlation between tion after several weeks. presence of malaria and number of It is also demonstrabl tru hookworms harbored. Eighty-eight y e cases in Java jail. (Table 42) that . the prisoners were. not acquiring new hookworm infec- tions; their respective complements of worms were brought in with them. In fact, there was a tendency for them to lose worms the longer they stayed in prison. The more severe cases of hookworm infection, as well as some other hookworm cases, were probably weeded out by treatment, for about 10 percentofthe menin the treatment squads had been treated with chenopodium in the hospital adjoining the jail. Under these circumstances, the underlying causes that have led to a correlation between low worm counts and negative spleens are not known. Perhaps a better idea of the situation may be obtained if the cases are analyzed with special regard to the relation of worms to plasmodia, as is done in Table 43, page 167. The following points should be noted: (1) the higher average worm counts were encountered in the groups in which, at the time of exami- FINDINGS CONCERNING MALARIA 79 nation, plasmodia were absent but in which spleens were either palpable or enlarged; (2) lower average worm counts were found when plasmodia were associated with enlarged or palpable spleens; (3) the lowest average worm counts were found when plasmo- dia were absent and the spleens were negative; (4) the anemia is correlated, not with the presence or absence of plasmodia, but with a palpable or enlarged spleen. In one of the squads the exam- ination of blood for plasmodia was not made, but there were eighteen cases which may be analyzed with regard to splenic enlargement, number of worms, hemoglobin, and length of time in prison. In Table 44, page 168, which includes these eighteen cases in addition to the other treatment SPLEEN SPLEEN SPLEEN NEGATIVE PALPABLE ENLARGE!) 63 25 34 AVERAGE (m cm Encomm macaw (AVERAGE NUMBER) Fig. Win—Correlation between splenic av no“ IMO 6 Z In 60 I“: )4, 1“ 8 z 70 . no 5 a 5A5 : 9 5° izo‘g 3 s 5 so :00; I E 5 4° so 5,: E 30 so ‘6 E l . m 2‘: 20 I ‘ 40 'u‘d 5 IO 20 3 D 0 535:: ES 55 is 2:5 (20%“552‘3u g: 0 SE '2 35° 452 #8 ‘22 :25 a. 5 Zuni, {US 53} €53,533: 2‘” 2 2““ 23:2sz egg Sat!“ xé z m; mg mg: sun is" g a"; a as 5; as as :E 5 s; g - AVERAGE HEMOGLOBIN (PERCENT) HOOKWORMS HARBORED (AVERAGE NUMBIR) Fig. 73.——Relationship between number of hookworms harbored and presence or absence of malaria plas- modia. Eighty-eight cases in Java jail. (Table 43) squads, it will be seen that there is avery marked positive correla- tionbetweenenlargedspleensand number of worms, and that, as regards this correlation, the palpable spleen occupies a place intermediate between the negative spleen and the en- larged spleen. There seems, however, to be little or no correlation between plasmodia and worms, when cases are taken irrespective of the condition of the spleen. The average number of worms associated with plasmodia was 76.7 and the number of pa« tients with plasmodia absent at the time of examination was 74. (See Table 43.) In condition and number of hookworms the negative~spleen $0.11.?» hOW‘ harbored. One hundred six cases in ever, there was a POSIthC cor- Java jail. (Table 44) relation between plasmodia and 80 worms. Anemia was also posi- tively correlated with worms and splenic enlargement. The degree of splenic enlarge- ment increased with the dura- tion of exposure to malaria infection, and in the negative- spleen group the presence of plasmodia was negatively corre- lated with length of exposure to malaria. It is to be inferred, therefore, (1) that plasmodia are more apt to be demonstrated in the earlier periods of jail residence, (2) that splenic en— largement occurs with greater frequency in the later periods of residence, and (3) that the men receive in the jail more malaria than they bring in. This is borne out by the observation that 92 prisoners confined from 1 to 3 months had an average hemoglobin of 83.5 INTERNATIONAL HEALTH BOARD IOO 9 o 55-5 m an 39 .‘o‘ AVERAGE HEMOGLOBIN, PER CENT usesquxa 557a! EE “" 5 ‘21 '& E: :42 Z :0 Ma 3?— r— o t- < 25 53 :3 as :3 :1 a: u: 5 z a ‘2'“: gm Em ( O F- (DNDITION 0F SPEEN - I r0 3 MONTHS JAIL. nESIoENCE m (mo 72 mums JAIL RESIDENCE Fig. 75.—Hemoglobin rate and degree of splenic enlargement in relation to length of jail residence; per cent, while the average of '°° 91 90 so 19 Ill 58 7o 69— 67 7° 12 “‘Z 65 a— as (I)! 6| fig 60 55 “a4 .— 50 as as :3 40 :v— :2 we 50 “r: mm 50. 20 lo CASES 594 25 92 42 no 51 we us 45 23 25 22 §§§££§§222§ 0 z z E g o 5 E E g <3 §d§22s552*=£ gwmumgrum-vgll"; S E E 2 e a e a E a S as _ ‘1 :~ 2 fl 3 5w 3 :5 :3 LENGTH or JAIL RES|DENCE Fig. 76,—Splenic enlargement in relation to length of jail residence; 594 cases in Java jail. (Table 46) 115 cases in treatment squads in Java jail. (Table 45) the total (594) was 77.1 per cent. (See Table 45, page 169.) Furthermore, of 25 men who had been in the jail for periods of nine days and under, and who re- ceived examination, 16 had neg- ative, 4palpable, and 5 enlarged spleens—a spleen rate of 36. This splenic enlargement must have been brought in with them. The frequency of splenic en- largement increases markedly during the first 6 months of jail residence. (See Table 46, page 170.) The correspondence between splenic enlargement and high average worm count, so far as this jail is concerned, may be explained by the fact that men free from malaria come into the jail from regions where there is little or no malaria, but where FINDINGS CONCERNING MALARIA 8I there is considerable hookworm infection. The men with high worm counts and anemia might be more liable, after malaria infec- tion, to acquire and retain a degree of splenic enlargement. Here it would seem possible that hookworm infection with anemia might render a person more susceptible to malignant influences of malaria -——in the case of those free from malaria and harboring a large number of worms, who take up residence in a malarious locality and become infected with malaria. But we should not eliminate, in considering the series, the possibility of cases occurring which, pre- vious to entrance, already had a large complement of worms, owing in part to the lowering of resistance to hookworm re-infection by attacks of malaria. Control Investigations in the Fiji Islands. It was clear to the Commission that, for the purpose of control facts and figures, it would be necessary to study conditions in some com- munity known to be free from malaria in an endemic form. While it is true that hookworm infection is universal in the tropics, mala- ria is not co-extensive with it. For instance, .Barbados is free of malaria; the same is probably true with respect to some of the estates on the flatlands of the Federated Malay States, and some districts in Java and Sumatra. But it was deemed desirable, in order to eliminate all doubt, to make the control investigations in some of those islands of the Pacific which were known to be en- tirely free from endemic malaria. This condition prevails among the islands of the Fiji Archipelago. It will be remembered that the investigation in the Federated Malay States had been made among the coolies from South India. Therefore,inasmuch as many Indians, both free and indentured, were to be found in the Fiji Islands, the conclusion was reached by the Commission that no better place for making the control studies could be found. The observations of the Commission were confined to the largest island in the Archipelago, Viti Levu—to territory on the south side of this island and, for the most part, in and around the town of Nausori, and among the coolies living on the plantations along the Rewa River. Both the native Fijians and the Indians examined here were apparently in good physical condition. The indentured Indians were in rather better condition than the free, or time- expired, coolies. The work was begun with a preliminary malaria survey. Groups were assembled and clinically examined for evidence of enlargement of the spleen and for clear indications as to hemoglobin content. Like groups were then carefully tested for hemoglobin percentages, and blood examinations were made for the purpose of discovering any direct evidence of malaria. This work was conducted as follows: among the persons in the Colonial jail at Suva; among the indentured Indians working in the sugar 'factory at Nausori; among both the indentured and the free Indian shopkeepers and artisans working in the village of Nausori; among the Fijian 82 INTERNATIONAL HEALTH BOARD youths, practically all of whom were either sons of chiefs or else from some of the other high-caste families, attending the Queen Victoria School; among Fijian men, women, and children in the villages of Nausori and Vanimora (both river towns); among Fijian men, women, and children in the village of Nasaqo (which is a mountain town); and among European men, women, and children in the village of Nausori. Of the 529 who were examined for indications of malaria plas- modia, 297 were Indians, 158 were Fijians, and the rest were Euro- peans—half—castes and Polynesians of all ages and both sexes. In the examinations for indication of blood parasites—plasmodia and filaria—thick film stains, obtained by modification of Hasting’s stain, were employed. None of those examined were found to be posi- tive for plasmodia and, respecting all those examined for enlarged spleens, only 5 palpable spleens were found among 57 patients exam- ined at the Suva Hospital, 1 among the 64 boys examined at the Queen Victoria School, and 6 (all in the case of North Indians) among the 885 Indians and Fijians who were examined on the plantations along the Rewa River, near Nausori and Nasaqo. Careful search was made near Suva, Nausori, and Nasaqo for anopheline larvae, but none were found. Clearly, therefore, malaria was not found endemic in the districts visited by the Commission, and the medical history of the people- as drawn from the reports of the Chief Medical Officer and from con- versation with medical practitioners, planters, and officials—together with the absence of anopheles, convinced the Commission that the island was entirely free from this disease in an endemic form. Par- oxysms of malaria are said to attack indentured coolies occasionally during the first year or two after arrival from India, but no evi-‘ dences of acute or chronic malaria were found in any of the more recently arrived indentured coolies examined by the Commission. Nor was a history of dysentery obtained in more than two or three cases. The anemia observed may therefore be properly attributed to the effect of hookworm infection, intensified more or less in certain classes by an insufficiency of food. CHAPTER VIII FINDINGS CONCERNING ANEMIA Hemoglobin Standards in Relation to Race, Age, and Sex. The principal question to which the Commission was expected to find an answer was, “To what degree is Uncinaria infection a menace to the health and working efficiency of the people of Malay?” In order to answer this question it was necessary to give some relative weight or value to hookworm infection, associated as it nearly always is, with malaria. It would be necessary to find out in any given community the degree of anemia due to hookworm infec- tion. The damage done by malaria ———as indeed also the benefit derived from treatment for hookworm infection—is expressed in terms of average loss or gain of hemoglobin per individual. It is quite clear, then, that if we wish to state to what degree hookworm infection is a menace on A. B. estate, the factor may be best expressed in terms of lost hemoglobin per individual. But if we wish to state to what degree it is a menace on X. Y. estate, where there is also severe malaria, it is a problem to know how it shall be estimated and expressed. Individual cases of infection, it was found, could not be properly compared on account of the unknown factor of individual resistance or perfection of defense. But when all the cases were bulked and averaged it was observed that there was some correlation between degrees of anemia and numbers of worms, and this fact led to the conclusion that it would be possible to work out a factor which would express, if only crudely, the amount of anemia caused by a given number of worms. However, it was not so simple a matter to work out this factor, as several difficulties were met which had first to be overcome. In the first place, it was found impossible to estab- lish a single standard of hemoglobin for a total population. A fact not generally recognized is that the hemoglobin differs considerably in the two sexes and in the different periods of life, and yet this dis- parity is so marked that for purposes of exact comparison groups must be considered. Examination of large numbers of apparently normal people disclosed considerable variation from the average which exists through all the decades of life and exhibits a marked degree of con- sistency. A fairly large number of individuals were examined in an effort to ascertain the hemoglobin percentages of the sexes and of various races at different periods of life. Many interesting facts were brought out by these examinations. It was found, for instance, that age influ- ences the hemoglobin values, not merely during adolescence but dur- ing the entire period of life, so that different values must be assigned to each decade. To illustrate: it was found among the kampong people that the highest point of the wave was reached during the third 83 84 INTERNATIONAL HEALTH BOARD decade, the 20—30 years period. The lower values began to‘ show themselves in the next decade. After the fiftieth year a very decided drop was found to occur, reaching at times the values seen in early childhood. The examinations conducted among the Tamil coolies at Port Swettenham, among the Chinese coolies at St. John's Island (Singa- pore), and among the natives of Java proved conclusively that there was a very marked difference between the hemoglobin values of men and the hemoglobin values of women. At Port Swettenham, with the Dare's instrument, hemoglobin determinations were made on 2,261 Tamil coolies. Of the 1,659 men thus examined, the majority showed a hemoglobin average of between 80 and 89 per cent, and the major- ity of the 452 women, and 150 children under 12, examined showed a hemoglobin percentage of between 70 and 79. In other words, the average hemoglobin among the men was found to be about 10 per cent higher than among the women. It was found that the effectof pregnancyon the hemoglobinwas very striking, and seemed to be more noticeable in the later months. Again and again this reduction in hemoglobin value due to pregnancy was encountered, oftentimes amounting to as much as 15 per cent below that of the normal non-pregnant women of the kampong. This is probably attributable to hydremic plethora, a condition which, although normally encountered in pregnant women, is also probably a frequent occurrence after puberty in non—pregnant females whose hematopoietic system is overtaxed. The reason for this explanation is the fact that a number of women were found who were suffering from anemia, and in whom no other cause of anemia could be elicited. Malaria was absent at the time of examination, and the number of hookworms was too inconsiderable to be assigned as a cause. Obser- vations would seem to indicate that females are very much more unstable as regards their reaction to an anemia-producing cause. (See also section “Greater Severity of Anemia in Women," page 115.) The fact that a very large proportion of the women were found preg- nant added considerably to the difliculties of the Commission in deter- mining the hemoglobin standard of women. In the course of its investigation the Commission found in Java a place in which there was no malaria. Anthelmintic treatment of a representative group of the dessa people disclosed the fact that very few worms were harbored by them. The incidence of infection as determined by treatment was 52 per cent, and the average number of worms per individual was only 6.3. Thirteen men whose ages ranged from 17 to 50 showed an average hemoglobin content of 99.3 per cent. Nineteen children whose ages ranged from 5 to 14 showed an average hemoglobin content of 90.1 per cent. This group of people, who lived and worked at an altitude of 3,600 feet, was relatively the freest from malaria or hookworm infection of any people investi- gated anywhere. Four of the men treated were found to have hemo- globin percentages of 96, 98, 101, and 104, respectively. Were it not l“ig. 77.¥'l‘ypes of natives in treatment squad at Tji- matjan, Java. Living at an altitude of 3,600 feet, free from malaria, and have very little hookworm infection. A fine sturdy lot. Spleen and parasite rate, nil; hook— worm incidence, 52%); average hookworms, 6 l’ig. 78.—A vigorous dessa man carrying his plow on his shoulders to the fields. Hookworm infection in the district very light ~568ch 553x00: 8 Ho: wcm “$335 9 kmoEo 26 mm MESS” 30:? J. was “M «N mo 83 2: E Ewwofiocvfim 802 S m mo 3 8:0,?» 26:55: 36:58: 3075 A; mmium 3203 .33 QENBNQ macaw mm mm 2 mm €2.35: .fififiwfl ,wwawmmm 635m Eofibmufifildw .wmm @859: Eucumu: 308 mm 25mm“: 805 E comufismoa 85:0 U8 E2585 853x00: 33/. .:c :2onme ”RV”: 652m -080; omfigm ”Roma; 62$ 52% mva am“ -53.. KZBM 558 85% 730R. .Cmmosmg wcw Emmwcfimm 80¢ £153 £15 c2835 EBB -xoo; we 3me :33 895 was? 2: cHldn .mmm FINDINGS CONCERNING ANEMIA 87 for the fact that these people were living at so high an altitude, to which fact their higher hemoglobins could conceivably be attributed, they might well be regarded as a satisfactory group from which to derive an average hemoglobin standard. Control determinations of hemoglobins of the members of the Com- mission were made at the time, and found to register several degrees lower than those of the natives infected. The average hemoglobin of the members of the investigating party was found to be 87 per cent, which is what it had registered at sea level on several previous occa- sions. It was therefore thought unwise to use a high altitude index as a standard with which to compare people living at or near sea level. It was felt by the Commission to be highly desirable, if possible, to derive a number based on actual determinations with instruments, rather than to take an arbitrary number as the standard of the nor- mal hemoglobin content. This of course means that in order to determine, with any degree of accuracy, what is the normal average hemoglobin of a mixed population, nearly all of whom are infected with hookworm disease, it is necessary first to separate the people in- to sex and age groups and determine the hemoglobins of these groups. Therefore, in the Commission's investigation of the subject in the Java kampongs that were free from malaria, the people were divided into sex and age groups. A group from a kampong highly infected with hookworm disease, and presenting cases of anemia, was com- pared with a corresponding group from a kampong more lightly infected. It was observed in the kampongs where there was much malaria that there was no close correspondence between the degree of anemia, which was usually severe, and the number of worms har- bored by the people. On the other hand, in kampongs free or nearly free from evidence of malaria a high positive correlation was observed between the degree of anemia and the number of worms. It should probably be added that while this was true of averages it was not necessarily true of all individual cases. A standard hemoglobin for each group was determined from the data obtained. The problem, as presented in Fig. 81 may be stated as follows: the average hemoglobin of the boys in Kampong Kalimaro is 71.5 per KAUMARO BATAVIA Age in years 9.7 9.2 Number of cases 9. 14. Normal average hemoglobin of boys 85.0% 85.0% Average hemoglobin of boys treated in the kempongs 71.5% 82.3% Calculated loss due to hookworms 13.5% 2.7% Average number of worms harbored 106.0 20.7 Calculated number of worms required to produce e loss of l per cent L _' L 7.9 7.7 Loss due to hookworms . - .5- . 85.0- . = . Number of worms required to produce 1% decrease 4813-19 3293"77 Fig. 81.—Loss of hemoglobin caused by hookworms harbored. Based on examinations of 23 boys living in 2 Java kampongs 88 INTERNATIONAL HEALTH BOARD cent and their average worm count is 106. The average hemoglobin of boys in Kampong Batavia is 82.3 per cent, and their average worm count is 20.7. What should be the hemoglobin average of a similar sex and age group whose worm count is zero? There were sufficient data for working this out for men, women, and boys. The standard for men was worked out, first, by plotting the average hemoglobin and the average number of worms obtained from the men of Kali- maro; next, by plotting the same for the men of Kebasekan (Fig. 82). LEMON" HEIOGLOBIH 90 80 70 50 40 30 20 10 NUMBER OF WORMS Fig. 82.—Method of determining the normal average hemoglobin A line from the first through the second intersected the line of no worms at the point represented by approximately 95.0 (i. e. 94.8) per cent hemoglobin. This is what we should expect to find as being the average normal hemoglobin of men in general. Fig. 83, page 89, presents in more detail the data regarding men in two Java kampongs. As a basis for discussion we shall use 95.0 per cent as the average normal hemoglobin for men, ascertained by the instrument that was used. This calculated percentage of hemoglobin (94.8 per cent) was rarely or never found among the kampong men, for there were sev- eral causes tending to lower the hemoglobin content. It was nearly approached, however, in a group of well-fed men in the Stadsver- band, Batavia. This was a group of beriberics, Chinese and Malays, FINDINGS CONCERNING ANEMIA 89 KEBASEKAN KALIMARO Number of cases 10. 9, Calculated normal average hemoglobin 95.0% 95.0% Average hemoglobin of men treated in the kampongs 74.9% 62.8% Calculated loss due to hookworms 20.1% 32.2% Average number of worms harbored 235.5 378.4 Calculated number of worms required to produce a loss of 1 per cent hemoglobin 11.7 11.8 Loss due to hookworms 950-743-2011: 95.0-62.8-3227u Number of worms required to produce 1% decrease £§§%—=11.7 —3-‘37s2-8:‘24—=11.8 Fig. 83.—-Loss of hemoglobin caused by hookworms harbored. Based on examinations of 19 men living in 2 Java kampongs at one end of a ward. The men were all well nourished, but on ac- count of physical disability were unable to work. They were living in a screened ward, free from malaria, and were able to maintain high hemoglobins. The range of hemoglobin was 85 to 97 per cent, and the average for the group of 9 men was 92.3 per cent. In working out the standard for the women a marked difficulty was encountered. The cases of the women at Kebasekan exhibited a very definite positive correlation between the amount of anemia and the number of worms, as is seen below: Percentage of hemoglobin 40, 46, 60, 69, 84, 85, 86, 88 Number ofworms 433, 261, 400, 31, 31, 38, 97, 9 The average hemoglobin was 69.7 per cent, and the average number of worms was 163.3. The average age of the women was 32.2 years, the range being 18, 18, 30, 32, 35, 40, 40, 50. On the other hand, the women of Kalimaro were all under 22 years, the average being 20.5 years, and the range 18, 20, 20, 21, 21, 22, 22, Of the seven, 4 were nursing infants at the time and the 2 with the lowest hemoglobins were pregnant. It had already been found that the pregnant women might have hemoglobin values of 15 per cent less than the non- pregnant women of the kampong. It was preferred, therefore, not to estimate by this group of women in calculating the standard. Instead, the group from Kramat and Kebasekan was used. Kebasekan Kramat Calculated for no worms Number of cases 8 5 ... Average hemoglobin 69. 7 85.6 86.5 Average worms 163 .3 9.0 0.0 The standard for boys was derived from Kalimaro, Kebasekan, and Batavia. The standard 85 per cent for boys will be used, as representing the normal average hemoglobin percentage for this group. There were no cases of anemia among the girls, and no marked differences in the worm counts or in the hemoglobin values. On this account we shall use the standard derived for boys. 5 90 INTERNATIONAL HEALTH BOARD In the case of women and boys, Kampong Kramat was used for comparison with Kebasekan and Kalimaro. The worm counts were very low in Kramat, and the loss of hemoglobin may have been com~ pensated. In that case 85.6 per cent for women and 82.3 per cent for boys should be used as a standard. In the case of men the standard is derived from two groups having definite but different amounts of measurable anemia. Anemia Caused by Hookworm and Malaria. Malaria is very common in the tropics. Indeed, malaria and hookworm infection are so frequently complicated that the anemia resulting from the one has often been attributed to the activities of the other. On the whole, severe anemia due to hookworm disease is less common than severe anemia due to malaria. It would, of course, be very desirable to express numerically the relative importance of malaria and hook- worm infection in the causation of anemia, and their respective places in vital statistics. But unfortunately the subject is so complex that it is not possible to do more than record the unanimous conviction of the Commission that in the Federated Malay States malaria is the more serious infection, and that it causes far more anemia, debility, and death than hookworm disease. In the Federated Malay States so much malaria was found that it was quite hopeless to estimate the relative importance of the two infections, especially because of the impossibility of entirely elimi- nating, either in individuals or in groups of cases, recent and past ma- larial influences. In Java, on the other hand, while there were places with severe malaria and little hookworm infection, there were other places with severe hookworm infection and little or no malaria. It is true that the number of cases in the series studied was small, but the absence of malaria was so nearly complete that the data have been used in an attempt to ascertain the relative values of the two infections in Java—that is, in places where the malaria is as severe as it is in many places in the Federated Malay States. The data obtained, and here presented, indicated that in regions where there is hookworm infection uncomplicated by malaria, per- sons may harbor a considerable number of worms without showing any measurable degree of anemia. In the same community, groups of persons were sometimes found with a large number of worms and a definitely measurable amount of anemia; other groups, also, were found consisting of persons with anemia of a more severe grade, and with a still larger number of worms. In the higher grades of hookworm infection, when the numbers of worms mounted into the hundreds, it is to be noted, in comparing the two groups—whose respective hemoglobins differed by several degrees—that a given number of worms caused a certain degree of anemia. The worms apparently caused a loss of hemoglobin at such a rate and in such an amount that the host was unable to counterbalance the loss, and the greater the number of worms the less able was he to compensate for losses. Thus, in the case of the highest worm count the loss of a FINDINGS CONCERNING ANEMIA 91 degree of hemoglobin is apparently caused by fewer worms than in the case of the medium grades of worm counts. If losses of hemoglobin are going on in the cases with moderate and high worm counts, which are measurable, it may be safely assumed that in lighter and lighter cases of infection, the gradations of losses are also going on, correspondingly lighter and lighter, but that they are counterbalanced, so far as we are able to measure them. There are reasons for believing that in places like Mid-Java, about 8 worms in a boy and 12 worms in a man may cause a hemoglobin reduction of one degree. This can be measured in places where the average worm counts of the boys are over 100 and the average worm counts of the men are over 200. Where the average number of worms harbored is very high, the worm factor, as worked out here, could be applied. Where the worm counts are small, the cases are few and it is not possible to say how much measurable loss is suffered by the persons with a few worms. This is due to the fact that there is little or no resultant anemia, to the small number of cases in the series, and to the normal range of hemoglobin in persons free from malaria and 'hookworm disease. The effect of the complement of worms in causing anemia is coun- terbalanced when the reserve powers are not interfered with. But if the reserve powers are weakened and broken down through malaria, malnutrition, under-feeding, exhausting labor, and other causes, the losses of blood due to the activities of the hookworms might not altogether be made up, and would probably cause anemia. It would be difficult to measure the amount in the presence of another cause, but when the reserve powers are entirely broken down—and this apparently is what happens in severe cases of malarial cachexia—one would expect hookworms to produce, in relation to number, the same amount of anemia here as when larger numbers are harbored, causing measurable anemia. On the average, a moderate number of worms, say 250, cause measurable losses of hemoglobin, and it is reasonable to assume that 50 worms would cause one-fifth as much, whether their effect was counterbalanced or not. Bookworm-Anemia Factor. In the presentation of this sec- tion dealing with an attempt to assign a definite value to each infec— tion as a cause of anemia, the expression has taken a numerical form but the numbers should be regarded only as relative and approxi— mate, for they are based on small numbers of cases. This cannot be emphasized too strongly. Efforts were made to get representative groups of the population, with hemoglobin determination and physi- cal examination as the basis, but it is likely that, if the places were re-visited, while essentially the same results would be obtained, the factor would not be identical. The absence of the complicating malaria factor is nearly complete in some of the dessas, so that the data are presented with the reservation that the figures must not be taken too literally. 92 INTERNATIONAL HEALTH BOARD The worm-anemia factor is based purely on Java findings. In estimating the losses of hemoglobin in Penal Institution No. 3, it was observed that the losses due to hookworm disease were markedly apparent only after the 100-worm group had been passed. In the kampong series there is a similar fall in values beyond the lOO-worm group, but there is also a progressive fall in hemoglobin values from the lOO-worm group to the O-worm group. In View of the positive correlation of worms to anemia beyond the lOO-worm group, it is difficult to account for the apparent discrepancy in the group with the smaller numbers of worms, unless it is due to small num- bers of exceptional cases. There is some doubt, therefore, in deal- ing with the series, as to the efiect of smaller numbers of worms in causing anemia. As a matter of fact, in rural districts it was unusual to find a small number of worms in persons liv-' ing under conditions in which they were free from malaria. This, however, may not have been due to any influence of malaria, but to greater liability of acquiring hookworm infection in the latter places,as atKebase- kan and Kalimaro. (See Table (ll - , - NORMAL HEMOGLOBIN AVERAGE ACTUAL HEMOGLOBIN AVERAGE 47- Page 171-) Itossmumosmm mmmonwmmsusr 1“ Sawah 395“ and Kramat BESSINHEMOGLDMMTDMALARIA there was little or no evidence , . . of malaria among the majority F'g' 84;*H0°k“’0”.n meCtlon of the people, and here the pres- and malaria as anemia-producrng ence of a few worms was corre- factors in dessas of Gebongelir, Java. 1 d . h h l b' 1 By sex and age groups. (Table ~17) ate w1t emog o m va ues a little below what was calculated for the normal, the indications being that there might be small losses of hemoglobin and slight anemia due to small numbers of worms. The number of cases was small, however, and in view of the range in hemoglobin among persons free from malaria or hookworm disease, and the efl'ect of other causes of anemia, the Commission was led to believe that the factor may be of use only when the number of worms is large, or in places where there is intense malaria and when all the worms are probably causing anemia. The factor is also an expression of the number of worms required to cause a unit amount of loss of hemoglobin in a population, irrespectiVe of whether it repre- sents total loss or loss that is partly or fully compensated. Some idea of the number of worms required to cause a loss of l per cent of hemoglobin may be obtained by dividing the average loss of hemo- FINDINGS CONCERNING ANEMIA 93 globin in any age or sex group into the average number of worms actually found to be harbored by the group. This method is illus- trated in Figs. 81 and 83. Here it is seen that the calculated number of worms required to cause a loss of 1 per cent hemoglobin in a boy is 7 to 8, while in a man it is 11 to 12. By means of these factors it is possible to calculate the amount of anemia caused in a district by hookworm, and the amount of anemia caused by malaria can also be estimated by difference. This was done in Gebongelir after a representative group of the popula- tion had been examined, treated, and their expelled worms counted. (See Table 47, page 171.) In this calculation it is assumed that only two causes of anemia are operative, and it is estimated that among the men 6.9 per cent of their anemia is due to hookworm and 32.0 per cent to malaria. Hard labor and sub-nutrition are undoubtedly strong factors in accentuating the anemia of people suffering from either malaria or hookworm. An attempt to estimate the effect of sub-nutrition was made among prisoners in the Batavia jail, Java. (See Table 49, page 173.) The effect of hard labor on prisoners was observed in Java, and an estimate of its effect on the hemoglobin percentage was made. In thejail, hookworm treatment was administered to some 109 men, and a re-estimation of their hemoglobin was made 3 months later. It was discouraging to find that the men had gained only 2.4 per cent hemoglobin per man. This was found to be due to the combination of contin- uous malaria re-infection and hard labor on a prison diet. An estimate was made ofthe amount of anemia caused by the three chief factors, hard labor, malaria, and hookworm infection. Given the assumed normal calculated hemoglobin of men as 95, the loss due to hard labor, y 8.0, or the difference between E 85.3 and 77.3 (i. e. the hemo- E globin of the clerks and of the MEN WOMEN Bars GlRLS prisoners at hard labor) is sub- -AVERAG£ HEMOGLOBIN [racted, the balance being 87, mHOOKWOHMS HARBOREDUVERAGE NUMBER) gfgcishggii militias]; 10:3 Fig. 85.—Average hemoglobin . rates and average number of hook- malaria. worms harbored in one malarious The average hemoglobin 0f andtwonon-malariousdessasofJava. men with malaria who were free By sex and age groups. (Table 48) 94 INTERNATIONAL HEALTH BOARD from hookworm is 76.5; this subtracted from 87 should give the amount of anemia due to malaria, or 10.5 per cent. The average hemoglobin in each worm group should now be 76.5 per cent if there were no hook~ worm infection; but the average hemoglobin of each group, by actual determination, shows marked reduction in the higher worm groups. The amount due to the activities of the worms may be calculated by subtracting the actual averages from 76.5, leaving a balance of 0 in the “0-worm" group, 1.2 per cent in the “1 to 100" worm group, 13.8 per cent in the ”101 to 200” worm group, 9.1 per cent in the “201 to 300" worm group, 26.5 per cent in the “301 to 400" worm group, and 39 per cent in the “-101 and over" group. Or if the 109 treated cases are taken, it is assumed that their normal hemoglobin should be .......................... 95.0% Deducting the average hemoglobin of all the treated groups. .69. 2 Balance=loss due to various causes ...................... 25.8% Deducting the loss probably due to hard labor, or the differ- ence between the average hemoglobin of 30 clerks and the average hemoglobin of prisoners at hard labor (85.3 —77. 3), = 8.0 Balance ............................................... 17.8% The average number of worms in the group was 79.5; when this is divided by the factor 11.7 (see Fig. 83) the amount of anemia due to hook- 90 worm appears to be so 79.S+11.7, or ....... 6.8 w 70 ._._.__ 53 60 B _ l E 50 alance—the 055 due to HJ g 40 malaria ............. 11.0% “J 30 a. 20 The effect of hard labor was 1% estimated by comparing the I0] 20' 30, 401 hemoglobin of 30 clerks at light 0 l-|00 To To TO AND occupation With the hemoglobin 30° ‘00 OVER of the other prisoners who were NUMBEROFHOOKWORMSHARBORED at hard labor. The diet was exactly the same in quality and quantity for each class, and each was infected with malaria to the same extent. The hemoglobin “NORMAL HEMOGLOBIN of the clerks was 8.0 per cent -HEMOGLOBINLOS$DUE10HARDUBOR higher than that of the men at mumoewsm LOSDUETOMALARIA hard labor. DHEMOGLOBINLOSSDUETOHODKWORMDISEASC The loss due to malaria was Fig. 86.—Respective losses in estimated bytakingtheaverage hemoglobin from hard labor and hemoglobin 0f 51" men not-m- sub-nutrition, malaria, and hook« {3‘3th Wlth hookworm and usmg worm infection. Prisoners in 83- this for comparison With the tavia jail, Java. (Table ~19) others. (See Table 4‘). page 173.) -mo-I ooo PERCENTAGE FINDINGS CONCERNING ANEMIA 95 In some of the dessas of Java an effort was made to determine the percentage of that loss which could be fairly attributed to malaria, and also ‘to determine the percentage which could be reasonably attributed to hookworm disease. Results in a given malarious dessa were analyzed, and an attempt was made to show how much anemia was due to malaria and how much was due to hookworm infection. Gebongelir, a fishing village on the north coast of Java, presents a striking example of a combination of hookworm infection and malaria as factors in producing anemia. (See Table 47, page 171.) The spleen rate here was 97 and the parasite rate was 29. Instead of combining the gross average hemoglobin values of the people of this malarious dessa with those of another dessa, free from malaria, it seemed best to compare the hemoglobins in respective age and sex groups. ‘This comparison showed that among the men malaria caused about five times as much anemia as hookworm infection; among the boys about three and one-half times as much; among the women, and perhaps among the girls, about fourteen times as much. The comparison of the calculated losses due to malaria in Gebon- gelir with the calculated losses due to hookworm infection in Kebase- kan and Kalimaro (see Table 47) gives one a fairly good idea of the damage done by malaria in a typical dessa in the densely populated flatlands of Mid-Java. The calculated normal hemoglobin of the men at Gebongelir was 95, of the women 86, of the boys 85, and of the girls 85. The calculated loss due to malaria in this dessa was, among the men 32.0, among the women 35.7, among the boys 22.1,and among the girls 15.5. The calculated normal hemo- globin in the dessas Kebasekan and Kalimaro was, among the men 95, among the women 86, among the boys 85, and among the girls 85 —the same as at Gebongelir. The calculated loss due to hookworm disease in this dessa was, among the men 25.8, among the women 16.3, among the boys 13.5, and among the girls 2.0. Estimated Loss of Hemoglobin due to Hookworm in a Population Subjected to Malaria. An estimate of the quan- titative value of increasing numbers of hookworms in causing anemia was also made by analysing the large number of cases treated in the Malay States. This series, excluding hospital patients, gave a total of 818 cases. Of these, 58 were boys and girls of mixed races, though mostly Eurasian, found in the Convent School at Kuala Lumpur; 75 were Malay boys found in the schools; and 92 were Tamil men, women, and children who worked on the public roads, and as night-soil coolies; 63 were Tamil men, women, and children who worked as coolies on rubber estates, and most of them had been exposed to malaria; 35 were Tamil men, women, and children detained in the quarantine camp at Port Swettenham; 58 were Chinese men, women, and children detained at the quarantine camp at Singapore; 55 were Chinese, Tamil, and Malay men at Prison No. 1; and 352 were 96 INTERNATIONAL HEALTH BOARD Chinese, Tamil, and Malay men at Prison No. 2. In these several groups treated and ex— amined for hookworm disease, persons of both sexes and of difierent ages were included, and all varieties of physical condition in the working popu- lation were represented. The fact that the cases came from schools, rubber estates, public works, quarantine camps, and prisons, means that both urban and rural populations were 5 5 .4 o o 2 u x b. O J) .n o .J < a: ‘s’ 1 0.0 2” represented. 2“ 35'”? 4 '5 '0 Tables were made dividing 3 3 § the whole series into classes, 0 3 :3 E 2 according to the numbers of 3 2 § worms expelled by treatment; NW” or Homwoms mm and the average hemoglobin of each class was calculated Fig. 87.—Estimated loss of hemo- and comparisons made. (See globin due to hookworm disease, Table 50 page 174_) among populations subjected to The hemo lobin avera e suf- malaria, by hookworm groups; 818 g . u g cases treated from schools, rubber fers n’o drop 1n the 1 to_ 5 estates, public works, quarantine worms group as compared Wlth camps, and prisons in Federated the “0 worm” group- As these Malay States. (Table 50) two groups contain a large num- ber of cases, the average ob- tained by combining them will furnish a good standard for comparison with the other groups. Taking the average hemoglobin of the ”0 to 5 worms" group, the difference between this and the average hemo- globin of each succeeding worm group will give the average amount of anemia caused by the corresponding number of hookworms. It will be seen that there is a steady loss of hemoglobin with an increasing number of worms. The rate of loss in the worm groups over 100 is higher than it is in the groups lower than 100. This is probably due to the host's ability to make good the losses due to a few worms. The smaller number of worms presumably has the same propor- tionate effect in causing loss of blood as has the larger number, but the effect of the former is masked and not readily measurable. In these tables a loss of hemoglobin is understood to mean the measur- able or evident effect of the infection, and does not include any loss which can be compensated for by blood regeneration. In the table based on analysis of all the cases, the average loss of hemoglobin is 4.3 per cent per case and the average number of worms is 53.]. Therefore the ratio of the loss of hemoglobin to the number of worms is 1: 12.3. ALA... @me ”8:032: 85,530: KNRQ Jam; 86.2mm ”figmw Jug coofim .833 2: so Eon £3 55:5 085 g5 25 ECO {Bananas—W 0883 52E 5an 2: we 088 £132: 23 we 512/8 05 8 26 :58 of wo 85895 oi U8 Escuum co $5 383mg mm a pan dwfltmuwmfi 098$ op EEO? Emcwua 5w uEmwwomEm Hm mm 3:0 Hon/H: “ES 33 fi 338 we on? 26. *0 .woufim kin: of We 2:508 05 E 338 ELLE 3223::3 Em co mE>= c2250 wo msopOIww .wE 38.8 mnotflmfi 33923 50¢ 955w @5305 “mm .mmm at? EmanU .bom, .8me 52% “Simon :NVNA £38 502% ofiumwo: mo Enofimofioz omwbiw RN53 .8592: 85.530; ”was “8.3 macaw .2538 80¢ aux ,3???wa 383 am so 283?? :Emrfildw .mmm \Ju. uriIXC» . § .. . ‘.I\..\\le.mvl? s A ‘ .. 6‘ nx _, ..,¢ ,\ H...» FINDINGS CONCERNING ANEMIA 99 The foregoing cases are taken irrespective of the evidence of malaria. When a separate analysis of the cases having evidences of malaria (plasmodia or enlarged spleen) is made, it is seen that the hemoglo— bins are set at a lower level, the average hemoglobin of the ”0-5 worms” group being 74.5. Among prisoners in Java it was 76.5, instead of 83.7 as in the group without evidences of malaria. This depression of the average hemoglobin is encountered in each group and is due to the effect of malaria. The difference between 83.7 and 74.5 (or 9.2) is due to malaria and may be compared with the amount 10.5 found among prisoners in Java. In 155 cases with evidences of malaria the average loss of hemoglobin is 5.9 per case below the “0—5 worms” standard (74.5), and the average number of worms is 84. Therefore the ratio of the loss of hemoglobin to the number of worms is 1: 14.2. In 663 cases without evidences of malaria the average loss of hemoglobin is 3.2 per case below the “0—5 worms” standard (83.7). The average number of worms is 45.8. Therefore the ratio of the loss of hemoglobin to the number of worms is 1: 14.3. The average loss due to hookworm is greater in the malaria cases, but the average number of worms is greater also. The fact that the ratio of loss of hemoglobin to the numbers of worms is the same in the malarial and non-malarial groups shows that the worms pres- ent exert an equal influence and the difference in loss of hemoglobin is due to the greater number of worms harbored by the malaria cases. This indicates that a given number of worms has the same effect on cases with malaria as it does on cases without evidences of malaria. However, in the groups containing a larger number of worms the losses due to hookworm are greater in the cases showing evidences of malaria. An analysis of the series into race, age, and sex groups may be made in the same way. In 361 Chinese men, women, and children the average loss of hemoglobin is 1.4, irrespective of evidences of malaria. The average number of hookworms is 22.1. Therefore the ratio of the loss of hemoglobin to the number of worms is 1: 15.8. In 172 Tamil men, women, and children the average loss of hemo- globin in the group is 5.3 per case, irrespective of evidences of mala- ria; the average number of worms is 106. Therefore the ratio of the loss of hemoglobin to the number of worms is l: 20. The Tamils show a larger loss due to hookworm than the Chinese, but the Chinese have a lower ratio between the loss of hemoglobin and the number of worms. This means that fewer worms are required to produce a given loss of hemoglobin in the Chinese than in the Tamils. It is shown elsewhere that Chinese harbor a greater number of A. duodenale than the Tamils do. This is a more malig- nant worm than Necalor americanus, and causes more severe anemia. Undoubtedly the difi'erences noted above are due to the large pro- portion of A. duodenale in the Chinese. In 459 men the average loss of hemoglobin is 1.7, and the average 100 INTERNATIONAL HEALTH BOARD number of worms is 41. Therefore the ratio of the loss of hemoglo- bin to the number of worms is 1: 24.4. In 44 women the average loss of hemoglobin is 9.9 per case, and the average number of hookworms is 98. Therefore the ratio of the loss of hemoglobin to the number of worms is 1: 10. In 160 children the average loss of hemoglobin is 5.3, and the average number of worms is 44.5. Therefore the ratio of the loss of hemoglobin to the number of worms is l: 8.4. These ratios show that to produce a given loss of hemoglobin more worms are required in a man than in a woman, and more in a woman than in a child. From this method of analysis the conclusions reached are: (1) that in a population the loss of hemoglobin due to hookworm dis- ease may be measured, within certain limitations, by comparing the hemoglobins of cases having high worm counts with the hemoglo- bins of cases with low worm counts; (2) that the greatest possible benefit to be expected from treatment may be estimated, with the same limits of error, in any hundred cases of the population; (3) that the effect of a given number of worms in cases with evidence of malaria is, on the whole, the same as that in cases without evi- dence of malaria, but in this series of 818 persons, the cases with evidence of malaria (i. e. plasmodia and splenic enlargement) showed a greater number of worms and a correspondingly greater loss of hemoglobin than the cases without evidence of malaria at the time of examination; (4) that fewer worms are necessary to cause a given loss of hemoglobin in Chinese than in Tamils, and that this is prob— ably due to the greater percentage of the more malignant Ancylos- tomes in the Chinese; (5) that fewer worms are required to pro- duce the same loss of hemoglobin in children than in women, and fewer in women than in men. Anemia in the Fiji Islands. In the course of its investigations in the Fiji Islands the Commission examined a group of Europeans consisting of 41 men, 10 of whom had been born in Fiji, the rest having resided in Fiji from 5 years and under, to 20 years and over. The average hemoglobin of these men was 88.8 per cent, which was the highest of any group examined on that particular island where the investigations were made (Viti Levu). As a rule they were living under excellent hygienic conditions. Upon examination of their stools it was found that only six were positive for hookworm disease, and even among these the number of worms harbored was apparently too small to influence their hemoglobin unfavorably, for their hemoglobins registered 85, 90, 91, 92, 94, and 100 per cent. Examination was made of 18 of the European women, all with the same length of residence on the island. Their average hemoglobin was found to be 83.9 per cent, which was the highest average found among the women. They were all free from hookworm disease. The average hemoglobin of the 13 European children examined, between 4 and 15 years of age, was 82.3 per cent. . s . FINDINGS CONCERNING ANEMIA IOI Three hundred twenty-three indentured Indian men were ex- amined. As a class, they were found to stand highest among the colored population, their average hemoglobin being noticeably su- perior to that of the free Indian men, either town dwellers or agricul- turists. Thirty of the former were examined and 139 of the latter. This superiority is doubtless due to the better hygienic conditions under which the indentured Indian lives, and to the medical inspec- tion and hospital treatment which he receives. Sixty-four Fijian boys were examined at the Victoria School, their ages ranging from 9 to 17 years. The average hemoglobin for the group was but slightly under that for the European men, i. e. 88 per cent. As a class, these boys stood very high. They were, for the most part, sons of chiefs and came from vigorous stock. Their nourishment had always been carefully provided for and it would be expected that their hemoglobins would be higher than those of less fortunate natives. It is pertinent to mention in this connection that in the treatment squad of Fijians from Nausori village there were two chiefs and their hemoglobins were the highest in the squad. There was very little difference between the hemoglobin contents of the free Indians and of the Fijians who lived in the villages near Nausori. The people in both groups were well-fed, comfortably housed, and not overworked. In all probability they were not exposed to hookworm infection to as great an extent as the free Indians living in the cane. The average hemoglobin of the Fijians stands a little higher than that of the Indians. Here, as elsewhere, the hemoglobin values of women were found to be influenced con- siderably by pregnancy. Wherever pregnancy was evident at examination, or was admitted by the women, the case was not considered in the tabulation of statistics. In fact very few women were included in the treatment squads, because there are reasons for believing that the statements of the women at the time of examination were unreliable. It has been thought best to base comparisons of worms and hemoglobins exclusively on the figures for men. Relation of Hookworm Disease to Anemia in Fiji. It had been hoped it would be possible to ascertain with some exactitude the effect of hookworminfection in causing anemia in a population free from malaria, but in order to do this it would have been neces- sary to compare the hemoglobin of men free from hookworms with that of men harboring various numbers of worms. But hookworm infection was found to be so nearly universal in the class of men from which it was desired to elicit information that it was not possible to find a single non-infected man to furnish a basis for comparison. The only portion of the adult male population free from hookworm infection was European, and with them diet and occupation would make direct comparison unreliable, for the reason that the more liberal diet, the lesser exposure to sun and rain, and the lighter labor of the European must give him a certain advantage. Attention should be called to the high hemoglobins observed in the well-fed but bedridden Chinese beriberics in the Batavia Stadsverband, and o! .u.’ ..'. ....-.. 102 INTERNATIONAL HEALTH BOARD to the higher hemoglobins of the prisoner clerks in the Batavia jail as contrasted with their fellow prisoners at hard labor. If such conditions as hard labor, jail regimen, insufficiency of food, and the like, influence nutrition and hemoglobin values, and if these conditions vary in different communities under varying circumstances of life, it would seem almost impossible to make any observations which would be strictly comparable. Attempts to com- pare Chinese, Tamils, Fijians, and Europeans, therefore, will be sub— ject to error resulting from differences in nutrition. The two species of hookworm, Ancylostoma duodenale and Necator americanus, it has been shown (see page 106, section, ”Relation between Species of Worms and Degree of Anemia”), possess different degrees of malig— nancy. It will be impossible, therefore, to make exact comparisons based on total worm counts where the proportion of the two species varies very much. It would be necessary to study a much larger number of cases than the Commission was able to study, in order to minimize discrepancies due to individual variations in hemoglobin. It is possible only to give the results secured in the limited time at the disposalof the Commission and to point out their probable indications. In attempting to ascertain the degree of anemia caused by different numbers of hookworms, adult Indian males have been taken as representative of the male standard of hemoglobin. Women and children follow a different standard, and (the former especially) show greater individual variations in hemoglobin. Fijians have been excluded from consideration because of the uncertainty as to what influence racial constitution, diet, and mode of life may exert on their hemoglobins. Besides, their numbers are small. Attention has already been called to the low hemoglobins encoun- tered among the Indians in the Suva jail. This was true of the entire group as well as of the individuals selected from the treatment squads. When it came to treating the men it was found that the number of worms obtained was insufficient to account fully for the degree of anemia observed. Later, examination and treatment of the indentured Indians at Nausori showed their hemoglobins to be uniformly higher, although they were harboring a slightly larger number of worms than the Indians in the jail. Apparently jail regimen tended to lower the condition of nutrition of the prisoners and made the noted differences in hemoglobin. The two groups of men harboring from one to fifty hookworms may be directly compared. Number Number Average. of worms of cases hemoglobm of group Jail prisoners 1 to 50 19 76.3 Indentured coolies l to 50 31 85.8 Here it is seen that although the indentured coolies harbored as many hookworms as the prisoners, the average hemoglobin of the FINDINGS CONCERNING ANEMIA I03 former was 9.5 points higher. This would seem to indicate that, irrespective of their hookworm infection, the indentured coolies who are regularly employed and paid, and who are free to diet themselves, do keep their bodies in a better state of nutrition and exhibit a higher standard of hemoglobin than the prisoners, and that the superiority of the former is due mainly to better diet. It is evident that if it is desired to learn the measurable loss of hemoglobin due to various numbers of hookworms we must note such differences as are encountered among two such groups of men as we have just referred to—differences in the hemoglobin values which we must attribute to something other than difference in num- bers of hookworms, for the number of worms (one to fifty) is the same in each group. Some contributory cause, or causes, of loss of hemoglobin must be present in the jail group. '°° Concerning the indentured 9° coolies as a class, it is not pos- 5° sible to say what the average 70 hemoglobin of a non-infected oo portion of the population might be, for there was no non-infected portion. The average hemo— globin of men harboring fewer than 10 worms was 88.8 per cent. Ifwe consider the group of inden- tured men who harbored from 1 to 50 worms, we find the aver- age hemoglobin of the 31 cases to be 85.8 per cent. Considering the next group, or those men with 50 40 5O 20 IO E m g x In! I I.“ as E g‘ < 0 5| l6 9 CASES CASES CASES l-SO 5l-IOO [OI-ISO from 51 to 100 worms, we find that the average hemoglobin of the 16 cases is 85.0 per cent. HOOKWORMS HARBORED - NON-MALARIAL;|NDENTURED mwm abouts-FIJI. stvtnnv mumugmnts: MEN m 3mm JAIL It may therefore be assumed that ifthe addition of 50 worms depresses the hemoglobin only 0.8 per cent, the hemoglobin of men free from hookworms should not be far from 86.0 per cent. One hundred worms, or fewer, do not seem to cause any measurable loss in hemoglobin. In the next group, the coolies have from 101 to 150 worms; the average hemoglobin of the 9 men is 81.8 per cent. Here, apparently, the load seems to be too heavy to be borne without measurable loss in hemoglobin. Attention has been called to the difference between the hemoglobin of the indentured coolies, and that of the prisoners in the jail who were living under a different regimen. The effect of prolonged mala- Fig. 90.—Diminished hemoglobin from prolonged malaria infection superimposed upon hookworm in- fection. Note: Heavy horizontal line indicates hemoglobin loss due partly to malaria and partly to jail regi- men. (Table 51) 104 INTERNATIONAL HEALTH BOAR]? ria infection superimposed upon men already infected with hook- worm disease may be seen by comparing the indentured Indian coolies with a group of Javanese from three kampongs and from the Batavia Jail, who were heavily infected with malaria. The data are exhibited in Table 51, page 175. Here the hemoglobins of a group of indentured Indians who were not heavily infected with hookworm disease, and who were not suf- fering noticeably from anemia, are compared with those of Javanese of similar classes who were suflering severely from malaria and who were at hard labor. The Indians were in good physical condition and were engaged in agricultural pursuits. Their hemoglobins were fairly high,but we have no doubt that if it had been possible to take them from the fields and put them on a regimen of very light exercise with a rich diet, their hemoglobins on the average could have been raised four or five points higher in spite of their hookworm infection. Considering the scarcity of labor, the approach of the cane-crushing season, and the time limitations, - it would have . . . . . been impossible 3 3 :0 2 9 9 n to carry out such HEMOGLOBIN RATE an experiment, ' and the strong a w a: o m E W x s z u. o x Lu a: 2 2 z Fig. 91.—Correlation between number of hook- b b'l' f worms harbored and rate of hemoglobin; 131 Indians pro at l lty 0 free of malaria but infected with hookworm disease such factors as at Nausori and in Suva jail. Fiji Islands. Each dlet and hard dot indicates one person. (Table 52) labor influencing the hemoglobin content can be assumed only from the observations on the night- soil coolies of Kuala Lumpur, on bedridden Chinese beriberics in the Batavia Gefangenis, and on the prisoners at Batavia and Suva. In the Hospital ward at Kuala Lumpur, observations on the slow convalescence from severe malarial anemia of some of the vegeta- rian rice-eating Tamil patients, when compared with the more rapid recovery of the meat-eating Chinese, suffering from anemia of simi- lar cause, undoubtedly have a bearing on this question. With the possible exception of the Fijians, the group of men har- boring from 1 to 150 worms, and having the highest average hemo- globins, is represented by the indentured coolies. The indications are that the Fijians would stand as high or higher, but the number of treated cases is too small to offer precise information on this point. FINDINGS CONCERNING ANEMIA 105 90 (303'2 , 7O 60 55.0 550 50 _50.0__ 4 .o 40 _ _, _,__4oo 350 .0 30 > 20 - — I50 10 0 0 § 5 I i NUMBER OF HOOKWORMS HARBORED [s Fig. 92;~C0rrclation between number of hookworms harbored and rate of hemoglobin. Based on Fig. 91. (Table 52) (PER CENT) AVERAGE HEMOGLOBIN & 0' O 0-50 5| - I 00 I0 I- I50 I5 I '200 EDI-250 RSI-300 30l-350 35l-400 l 5 Q am -850 _ 40| ”450 45I "500 50I-550 55] ~600 60I-650 65I- 700 I 06 INTERNATIONAL HEALTH BOARD The Fijian treatment squad contained two well-nourished chiefs, and the hemoglobins of the treatment squad were higher than those of the population from which most of the men came. These facts are brought out in correlation Table 52, page 176. The 131 cases included in this correlation table were all Indian men. They included Nausori Indians, both indentured and free, and a small number from Suva jail. All were infected with hook- worm disease to a greater or less extent. On account of the comparatively small numbers in the different worm and hemoglobin groups, and the inclusion of prisoners who were underfed, deductions must be made with caution. However, certain generalizations are possible. Judging by the disposition of the cases in the body of the table, no marked positive correlation of number of worms to measurable loss in hemoglobin will be seen until the 251—300 group is reached. If the cases with 250 worms or fewer are counted, it is seen that nearly 80 per cent of the whole group of 131 show little measurable loss of hemoglobin attributable to the worms found at treatment. Where the worm content is 251 or over, the loss of hemoglobin, as worms increase, is striking. As several cases of severe anemia were included, the proportion of low hemoglobins in the treated squads exceeds that found in the population as a whole, and the table gives the impression of a greater amount of hookworm anemia than was probably present in the community. The hemoglobin averages printed at the left of the table show great oscillation, as might be expected of averages of relatively small numbers of highly variable units. There is no striking reduction in average hemoglobin until the 301-350 group is reached, since the average of the 251-300 group (79.3 pér cent) is but little below that of the 0-50 group (82.5 per cent). When the worm content is 301 or over, a marked reduction in average hemoglobin is noticeable. The average hemoglobins of all worm classes below this point run from 10 to 50 per cent below the lowest of any superior class, i. e., any class with 300 worms or fewer. When the hemoglobin regis- tered above 85 per cent, there was little tendency toward decrease, even though hookworm infection was present. On the whole, the hemoglobins of this malaria—free group apparently kept up in the presence of a comparatively high number of worms. Beyond a cer- tain worm count the hemoglobins fell rapidly. Relation Between Species of Worms and Degree of Anemia. It was observed by the Commission that in cases of infection the same number of worms caused a greater degree of anemia among Chinese than among Tamils. As Chinese harbor much larger numbers of A. duodenale than Indians do, the fact was taken to indicate that Ancylostomes are more malignant than Necators. Two Chinese suffering from severe anemia were studied. Their faces were of a peculiar, waxy pallor, but there was no edema; mala- ria plasmodia were absent on admission, and their spleens were not palpable. Inasmuch, therefore, as malaria as a cause of anemia was Fig. 93.——Tamil and Chinese with severe anemia and waxy pallor. No improvement after treatment. The blood- forming organs had become exhausted Fig. 94.—Hospital patient just before discharge and after hookworm treat- ment. This man went out to work on a malarious estate, contracted severe malaria, and returned broken down and edematous Fig. 95.—Same case as Fig. 9-1. four and one-half months after dis- charge from hospital. Malarialca- chexia. This condition is frequently mistaken for hookworm disease FINDINGS CONCERNING ANEMIA I 09 absent, it was presumed from their appearance that they must have been harboring large numbers of hookworms. (See Fig. 93.) As a matter of fact, on treatment they yielded only 302 and 265 worms respectively. This fact naturally led to the inference that Ancylos- tomes, by giving rise to greater hemorrhage, might be the cause of a more severe grade of anemia than Necators. This inference was more or less confirmed by a post-mortem examination of a Chinese who harbored 1,203 A. duodenale and 116 N. americanus, and in whom there was profuse hemorrhage directly due to worm bites. The hookworms that were recovered were bathed and imbedded in pale, bloody mucus. Numerous worm bites were seen, surrounded by circular areas of hemorrhage, but such worm bites were not nearly so numerous as the number of attached worms. It is therefore evident that hemorrhage does not occur from every worm bite. Practically all of the hookworms found were in the jejunum; none were in the ileum. It was not uncommon in treatment cases to find A. duodenal: with bloody intestinal tracts; in fact, two of the three cases with lowest hemo- globins, treated in Penal Institution No. 3, showed bloody worms in the first washings after treatment. It was observed that among cases of infected Chinese on the one hand, with their large number of Ancylostomes, and among Tamils on the other hand, with their nearly purely Necator formula, equal numbers of worms did not cause anemia of equal severity. It was thought possible that the A. duodenale—with its larger and more strongly armed chitinous mouth-parts—might cause more hemorrhage and more anemia than the smaller,-weaker-mouthed Necator. A series of experiments was conducted and the results of the experiments were tabulated. Out of a total of 90 cases of Chinese, there were 16 that harbored 40 or more Ancylostomes—in addition to the Necators present. Five harbored from 46 to 129, and 6 from 85 to 265, while 5 harbored from 253 to 1,203. A clinical examina- tion showed that several of the patients were suffering from severe anemia. There were four deaths. Out of a group of 16 Tamils examined in this connection, there were only two cases of uncomplicated hookworm anemia. The first of these harbored no Ancylostomes and 710 Necators, and the second harbored 2 Ancylostomes and 1,061 Necators; both were anemic and had more or less edema, but neither was broken down. Of the 16 Tamils, 14, or 87.5 per cent, showed evidence of malaria, but in spite of this malaria and the number of hookworms harbored (mostly Necators) there were no deaths. In fact, in the group of 16 Chinese examined, only 8. or 50 per cent, gave evidence of malaria, although as a matter of fact the anemia present was very severe and 5 out of the 16, or 31.2 per cent, died. These facts are significant and indicate that Ancylostoma duodenale is probably a more powerful agent in the causation of anemia than Necator americanus. Another type of patient was found (a Tamil who had been a va- grant for one and one-half years) who had both malaria and hook- 7 IIO INTERNATIONAL HEALTH BOARD worm disease, and in whom edema, ascites, and diarrhea were evi- dent. Although 550 hookworms were removed~32.3 per cent being A. duodenale probably derived from Chinese sources—his condition, far from improving, actually grew worse. For five weeks after admission there was no change in the condition of slight edema and ascites. After the sixth week, the edema of the legs increased rapidly and this condition lasted for five weeks, after which the edematous condition diminished for two weeks, only to return subsequently for another period of two weeks. During the third week diarrhea made its appearance and was severest two weeks before the time when the edema was mildest, and all through the period of severe edema the diarrhea was equally severe. The severity of this case was due in part to the large number of A. duodenale. Severe Malaria (Cachexia) Mistaken for Hookworm Disease. In the hospital, study was made of a series of cases which included men free from hookworm but suffering from severe malarial anemia, with edema and debility. The importance of this particular series lies in the fact that while the wretched physical condition of the men was found to be entirely due to malaria, the patients were of the type whose symptoms are usually diagnosed by practitioners and intelligent laymen as cases of ancylostomiasis or uncinariasis. The malaria factor is almost always entirely overlooked. A typical case, with conclusive evidence that the condition found was due to malaria and not to hookworm, was that of Murugan, a Tamil dhoby. In July, 1915, this case was treated for malaria in the hospital ward. He was admitted on July 6, with malaria and hookworm disease. On July 8, the examination of feces for hookworm ova revealed the fact that a few were harbored. Examination of blood on July 8, 10, 12,14, 16, 19, 21, 23, 26, and 28 showed crescents. Examinations on August 2 and 3 showed the blood to be negative for plasmodia. The examination on August 4 again revealed crescents. Examina- tion on August 6, 9, and 11 showed the blood to be negative for plas- modia, and the examination on August 12 showed subtertian rings. From July 8 to 19 the patient received quinine treatment. On August 4 chenopodium treatment was administered and 39 hook— worms were recovered. On seven subsequent examinations (August 9, 10, 11, 12, 13, 14, and 17) his stool remained negative for ova. On August 9 he had a paroxysm of malaria and his temperature remained remittent for four days. On the fourth day plasmodia were again found. A slight edema of the feet, noticed upon admission, disap- peared rapidly. Before the paroxysm of malaria occurred, his hemo- globin had risen from 28 to 67. Five days after this his temperature reached normal, when there was no edema—then he left the hospital abruptly. Twenty-seven days later he returned, after spending the larger part of the interval at Kajang, twenty miles away. For three days he worked as a dhoby in Kuala Lumpur. His fever returned and he took quinine. Unable to work. he was cared for by his friends. FINDINGS CONCERNING ANEMIA I I I His face and legs began to swell and he returned to the hospital, presenting a wretched appearance. Investigation showed that he had severe anemia, that his face was pufiy, and that there was slight edema of legs and feet as well as some emaciation. The condition which he presented is frequently miscalled ancylostomiasis; but as a matter of fact his stools were found to be negative for hookworm ova on seven examinations. On the other hand, his spleen was greatly enlarged, below the umbilicus, and plasmodia were found in his blood—subtertian and B. tertian rings. It will be recalled that, when he left, his hemoglobin registered 67 per cent. Upon his return it was found that it had dropped to 12 per cent; while the erythrocytes had fallen from 66.3 per cent to 18.8 per cent. He responded to treatment and made a fairly rapid recovery, his hemoglobin rising to 68 per cent in 35 days, or an average of 1.6 per cent per day. The Commission found many similar cases. Investigation revealed a number of cases of Tamils or Malabaris who had severe anemia, edema, and debility, but who harbored only small numbers of hookworms. On account of the similarity of these cases to the foregoing, the cause of the symp- toms was attributed to malaria rather than to hookworm. Rate of Blood Regeneration in Bookworm Disease and in Malaria. As has already been pointed out, a special ward at the hospital at Kuala Lumpur was assigned to the Commission for its use. One of the problems which the Commission undertook to solve was whether or not hookworm infection retarded blood regen- eration in malaria, and, if so, to what extent. Chinese and Tamil coolies who were in a badly broken-down condition were admitted to the hospital. In some of these cases severe and extreme anemia was detected. When the examinations of feces and blood were being made of the 332 patients who were admitted into the ward, hemoglobin determinations were carried out on them at the same time. An analysis of the results disclosed a very striking difference between the hemoglobin contents of the Chinese and of the Tamils, when the findings (with reference to the presence or absence of malaria and hookworm disease) were compared. These examined cases fell into four groups: (1) those who had neither hookworm disease nor malaria; (2) those who had hookworm disease only; (3) those who had malaria only; and (4) those who had both malaria and hookworm disease. The classification “malaria only" merely implies the presence of plasmodia in the peripheral blood at the time, as detected in the thick film. Absence of hookworm disease may be taken to mean absolute absence, as well as, in some cases, such sparseness of ova in the specimen that they were not detected. Inasmuch as this usually means that few worms are present, it indicates that the anemia found was not due to the presence of any large number of worms. Absence of malaria does not necessarily indicate what may have taken place in the peripheral blood or in the viscera before 112 INTERNATIONAL HEALTH BOARD entrance to the hospital. As a matter of fact, the average hemo- globin of these cases showed that there had been a very severe loss of hemoglobin due to causes other than hookworm infection, but principally to malaria. Classification “neither hookworm disease nor malaria" means that there might have been very few hookworms present, and that the degree of anemia indicated was the result of a recent attack of malaria, although plasmodia had disappeared from the blood stream at the time of examination. In each class the Chinese showed a decided superiority to the Tamils, so far as the average hemoglobin was concerned. It will be seen by reference to the summary below that when the plasmodia or ova are demonstrable, the amount of anemia due to malaria is greater than the amount due to hookworm disease, there being about twice as much among the Chinese and about three times as much among the Tamils. Furthermore, it will be observed that the amount of anemia among the Tamils, due to hookworm disease, was found to be about twice as great as among the Chinese, while the amount of malaria was found to be about two and one-half times as great. Percentage Hemoglobin Chinese Tamils Neither infection 48 . 8% 42 . 2% With hookworm disease only 46.9% 38.7% Loss due to hookworm disease 1.9% 3.5% Neither infection 48.8% 42. 2% With malaria only 44.9% 31.7% Loss due to malaria 3.9% 10.5% It must be remembered, in noting these differences between the Chinese and Tamils, that to a certain extent they follow different occupations. The Tamils, for the most part, are employed on rubber estates and on public works, while the Chinese for the most part work in tin mines, or as vegetable gardeners, artisans, and shop- keepers. Thus, the races are exposed in varying degrees to malaria. The religious and caste restrictions of Tamils prevent them from eating beef or pork, requiring them to be to a considerable extent vegetarians. On the other hand, the Chinese have no such dietary restrictions and eat heartily. These differences between the races undoubtedly affect their liability to infection, and also their abil- ity to recuperate afterward. Behind such influences as occupation and environment as related to the amount of illness of the respective races, there appears to be something deeper and more of the character of ethnic vitality, temperament, or metabolism. During physical examination the reflex activities of the Chinese are at once noticeable, as is shown in the difficulty experienced by a“... FINDINGS CONCERNING ANEMIA 113 the examiner in taking their spleen rates. While the Tamils have a soft, flaccid belly-wall, usually free from rigidity, the abdominal wall of the Chinese almost jumps to meet the hands of the examiner. This rigidity is more or less a rule among the Chinese men, and inter- feres not a little with the rapidity or accuracy with which their spleen rates can be taken. This reflex nervous irritability is an index of something far more commonly seen in Chinese than in other races. There are other indications, also, that the Chinese as a race are more vigorous and resistant to disease than are the Tamils: for example, the comparative rapidity with which they convalesce from debilitating disease and the ex- traordinary way their tissues react to the virus of syphilis. Table 53, page 177, with refer- ence to the time required to raise the hemoglobin in anemic pa- tients, shows that a very disap- pointing feature of the hospital u: u: t! < s 5 z e E d) {cg o s u 3: § 1:: u > < 5" § fr? 2 .‘3 work was the inability to raise ° ‘ ' " the hemoglobin value up to nor- ”‘W‘LWN °" ““5“" mal after the patients had recov- ered from an attack of malaria, and after they had been treated and freed from their hookworms. Very often their general appear- ance would be good and their weight would have so increased that they would ask for their dis- charge, when as a matter of fact their hemoglobin registered only from 30 to 60 per cent. It F18. 96_.—Time required tcuraise was observed that the lower a hemoglobin ratesof anemic patients, man's hemoglobin was on ad- followrng treatments for malaria and mission the greater was the hookworm disease. Fifty-eight cases d‘fii l, . . - treated in special ward at Kuala 1 cu ty m getting It up to L h 't 1' T bl 53 60 or 70 per cent. It was also umpur 05p] a ( a e ) observed that when it registered 10 per cent or less it was usually impossible to raise it to 70 per cent within three months. The Commission was particularly anxious to ascertain whether hookworm infection retarded blood regeneration in malaria, and, if so, to what extent. In order to discover these facts it was necessary, (1) to determine the rate of blood regeneration in cases of pure hookworm infection; .(2) to determine the rate of blood regeneration in cases of uncomplicated malaria, if such cases could be found; (3) to ascertain, if possible, what effect one infection had on the other -—-whether each advanced as though the other were absent, or whether there was any accentuation of either infection; and (4) to note DAY 5 *v To RAISE HEMOGLOBIN INDEX 0 20996552Il 114 INTERNATIONAL HEALTH BOARD whether hookworm infection retarded convalescence from malaria, and whether relapse of malaria might not mask the benefit of book- worm treatment. It is true that the hospital yielded abundant mate- rial for investigation along these lines, but it is also true that a dis- advantage was experienced because of the fact that the patients frequently absconded from the ward during treatment (29.5 per cent of the 332), thus making it necessary to abandon many experiments altogether, or else begin them all over again. A number of important experiments were ruined because of relapse due to malaria.‘ How- ever, even this circumstance gave the Commission an opportunity to find the loss in hemoglobin during relapse, and at the same time to discover the effect of insufficient quinine medication in malaria. The cases infected with both malaria and hookworm disease, in whom the hemoglobin had been reduced below normal, were treated thoroughly and at once with quinine for the purpose of arresting the development of malaria plasmodia, and in order to put a stop to the losses of hemoglobin. After this, it was possible to note the rate of blood regeneration in the patients, some of whom were harboring few hookworms and some of whom had many. By noting the increase in the hemoglobin and the increase of erythrocytes at stated periods during convalescence, it was possible, by administering chenopodium treatment and by counting the number of worms harbored, to ascer- tain the rate of hematopoiesis in those cases that were convalescing from malaria who harbored few hookworms, and among those cases that were convalescing from malaria who harbored many hookworms. In order to determine the effect of harboring a large number of worms (presumably for a period of time so long as to exhaust the blood~forming organs to a degree where hematopoiesis would be slower than in a control that harbored few or no worms), two patients—as nearly in the same clinical class, so far as age, race, hemoglobin content, malaria, etc., were concerned as it was possible to obtain ~—were selected and treated, and their hookworms were recovered and counted. After several days or weeks, the rate of blood regen- eration after treatment was determined and the results were com- pared. The results of these several experiments to ascertain the rate of blood regeneration in malaria and hookworm infection may be stated as given below: a. Blood Regeneration in Uncomplicated Hookworm Infec- tion. In instances of uncomplicated hookworm infection among the Chinese, severe cases improved very slowly, the rate of increase of hemoglobin being about 0.44 per cent per diem. It appeared to be impossible for the hemoglobin to return to normal limits. This may have been due to the bad physical condition of the patients treated. for the Chinese usually do not go to the hospital until they are quite unable to continue at work. The rate of increase of hemoglobin in the Tamil who was a boy was much better, being 1.0 per cent per diem; but this is slower f Result of insuflicient quinine medication. A dishonest employe stole some of the qumine and falsely labeled the substituted solution that was used. FINDINGS CONCERNING ANEMIA I I 5 than the rate of regeneration after malaria. There is a long period, after complete removal of the worms, in which but very little change in the hemoglobin or erythrocytes is noted. This period consider- ably diminishes the per diem rate of increase. b. Blood Regeneration in Uncomplicated Malaria Infec- tion. It was difficult to discover cases of uncomplicated malaria. In the series treated, one of the patients continued to show for several days evidences of malaria by the presence of plasmodia. This symp- tom was probably due to insufficient dosage of quinine. His rate of blood regeneration, as measured by the increase in hemoglobin, was 1.2 per cent per diem during a period of 32 days. During that period while he had no plasmodia in his blood, the rate of increase in hemoglobin was 1.4 per cent per diem. Two cases that had been previously treated for hookworm disease, and presumably were free from worms. had relapses. The rate of increase in hemoglobin in these two cases was 1.6 per cent and 1.4 per cent; the increase in erythrocytes was 1.4 per cent and 1.0 per cent respectively per diem. In the cases of malaria and hookworm disease in which the number of worms present did not exceed 232 in the South Indians or 154 in the Chinese, the hemoglobin content and the number of erythrocytes do not indicate that the number of worms present interfered meas- urably with the rate of increase. A patient was able to regenerate blood after malaria as rapidly with a load of 205 worms as if he had had no worms at all. When the malaria was associated with a much larger number of worms it was difficult for a patient to recover promptly. There were only two cases in this series and they were both in very bad physical condition on admission; they were treated early. In one of these cases it has been shown that the burden of carrying 600 worms apparently overtaxed the blood-forming organs to an appreciable extent, for the rate of regeneration after removal of the worms was distinctly slower than in a control who had been as ill from malaria, but who had harbored only a few worms. But it must be noted that this particular control, who showed the better rate ofimprove— ment at that time, returned four and one-half months later very badly broken down. On this occasion the rate of improvement was not so good—in fact it was almost as bad as that of the control carrying the 600 hookworms. These data serve to emphasize the truth that the blood-forming organs may regenerate well enough under a strain, provided they are not exhausted; and it shows that exhaustion may occur with malaria, with hookworm disease, or with both. Greater Severity of Anemia in Women. Striking and appar- ently disproportionate amounts of anemia were discovered among the women on certain estates where there was severe malaria and among the night-soil coolies who were infected with hookworm dis- ease and malaria. It was observed that, while the women (as a 116 INTERNATIONAL HEALTH BOARD whole) among the natives in some malarious kampongs in Java had hemoglobins usually up to what may be regarded as a dessa standard, pregnant women—particularly those in the last half of the period of pregnancy—showed a lower value. In the case of kampongs where the average hemoglobin of the pregnant women was found to be only 64.1 per cent, this fact is probably not to be regarded as altogether due to anemia, but to hydremic plethora, for women have a mechan- ism for the production of hydremic plethora; this mechanism is normally doubtless controlled by their endrocrinal glands. Some of the extreme cases of anemia in women may have been due to a perverted functioning of the glands as a result of severe malaria infection. The greater instability of the hemoglobin values of women may be ob- served by comparison of a group in those kampongs that were free from malaria, although "“‘R'ous “mm“ heavilyinfected with hookworm disease, with a similar group who had severe malaria and but few hookworms. (See Table 54, page 178.) It will be observed by refer- ence to this table that the incidence of hemoglobins 59 per cent and lower was 2% times .usrsmm HEMOGLOBlN 59 ANOUNDER greater among women than umstsmmmomusomoovmnr among men, among the treated EcbgsmnzuochnquwuNfl ~ . .. ) cases in the malarious dessas, NUMBER OF CASES 5.5 E a: ’2' 2 - , Fig. 97.—Severity of anemia in and therefore if the hemoglobin men, women, and children. Com- content 0f the women actually parative hemoglobin rates of sexes represented anemia, then the in malarious and non-malarious amount of anemia caused by districts. (Table 54) malaria is 2} times greater in women than in men. It was found that twenty-one twenty-sixths, or 81 per cent, of the women in the malarious dessas had hemo- globins of 59 per cent and lower, while only four-fifteenths, or 26.6 per cent, of the women who lived in the dessas which were non—malarious but which were heavily infected with hookworm, were in the same hemoglobin class. It is therefore safe to say that malaria causes three times as much anemia among the women in these kampongs as hookworm disease does in the other two kam- pongs. The fact that low hemoglobin values were found in preg- nant women—and in women suffering from severe anemia due chiefly to malaria—should be kept in mind in estimating the average hem- oglobins in various populations. FINDINGS CONCERNING ANEMIA II7 Anemia Among Chinese Coolies in Tin Mines. The Com- mission examined 200 workers in a tin mine, all of them Chinese. One hundred specimens of feces were collected. With respect to the hemoglobin content of these men, it was established by compari- son with 303 Chinese prisoners at Penal Institution No. 2 that anemia was not present to any marked extent in the mine. The lower percentages of hemoglobin found in the jail were not met with among the workers in the mine. In fact, the lowest hemoglobin in the mine series was 45 per cent, while the lowest in the jail series was 35 per cent. This difference was probably due to the fact that there was a weeding-out process at the mine, whereas all sorts and condi- tions of prisoners were admitted and retained in the jail. It was found that the higher hemoglobins among the mine series were slightly inferior to those found in the jail, the highest in the mine being between 85 and 89 per cent, while the highest in the jail was between 90 and 94 per cent. This difference could be explained as probably due to the better conditions, the better food, etc., in the jail, and also to the fact that the average age in the mine series was somewhat higher than in the jail series. It was found that the hemo— globin content of the underground workers was slightly less than that of the surface workers, the average among 59 underground workers being 83 per cent, and the average among 141 surface workers being 84.2 per cent. One hundred stools were collected and examined. Of the 32 underground workers, 84 per cent were found positive for hook- worm disease, and 79.4 per cent of the 68 surface workers. Of 100 of the stools examined, 81 per cent were found to contain hook- worm ova, which is almost exactly the same percentage as that ob- tained by examination of the feces of prisoners in thejails, i. e., 80.3 per cent. No correlation was observed between the degree of hookworm in- fection and the amount of anemia, for although the underground workers were shown to have the lower hemoglobins (a fact quite in accord with their greater infection with hookworm) the cases found infected with hookworm showed no anemia when compared with the cases not infected. That is, the average hemoglobin of 81 cases infected with hookworm was found to be 85.1 per cent, while the average hemoglobin of 19 cases found to be not infected with hook- worm was 80.8 per cent. As for malaria, it was found to be unimportant. Enlarged spleens were found in 25 of the 200 cases, i. e. 12.5 per cent. The cases with enlarged spleens and average hemoglobin were 78.6 per cent. The other 175 cases had an average hemoglobin of 84.5 per cent. Blood examinations were made of 162 cases, and 3 of these, or 1.9 per cent, were found positive for malaria plasmodia, their average hem- oglobin being 68.3 per cent. ‘I . . ..w... J ,I .. .y ..I..llh|l?\ _ .1. . ”1...... p. g. I. TABLE 1 POPULATION OF FEDERATED MALAY STATES BY RACE CENSUS OF 1911 Chinese Malays Indians Europeans Eurasians Others State All Races No. P.C. No. P.C. No. P.C. No. P.C. No. P.C. No. P.C. Total ...... 1,036,999 433,244 41 .8 420,840 40.6 172,465 16.6 3,284 .3 2,649 .3 4,517 .4 Perak ........ 494,057 217,206 44.0 199,034 40.3 73,539 14. 9 1,396 .3 845 .2 2,037 .4 Selangor ...... 294,035 150,908 51 . 3 64,952 22.1 74,067 25.2 1,348 .5 1,255 .4 1,505 .5 N. Sembilan .. 130,199 40,843 31.4 69,745 53.6 18,248 14.0 403 .3 464 .4 479 .4 Pahang ...... 118,708 24,287 20.5 87,109 73.4 6,611 5.6 137 .1 85 .1 496 .4 (Fig. 2, page 1) OZI GHVOH HL’IVEIH ’IVNOILVNHEILNI TABLE 2 PERCENTAGE INCREASE OF 1911 CENSUS OVER CENSUS OF 1901 All Races Chinese Malays Indians Europeans Eurasians Others State No. P.C. No. P.C. No. P.C. No. P.C. No. P.C. No. P.C. No. RC. 1901 678,595 301,463 313,205 58,386 1,459 1,526 2,556 Total -i1911 1,036,999 52-3 433,244 43-7 420,840 34-4 172,465 195-4 3,284125‘1 2,649 73'“ 4,517 76-7 1901 329,665 150,239 142,168 34,760 672 591 1,235 Pm“ ~~§1911 494,057 49-9 217,206 “£199,234 400 73,539‘”6 1,2961”7 845 43-0 2,037 649 1901 168,789 109,598 40, 40 16,847 11 580 613 Selangor.%19” 294,035 74.2 150,908 37.7 6495? 59.8 7$673396 134816181355116415051455 Negri.,.. 1901 96,028 32,931 56,93 ,26 142 309 185 Sembilan.§19ll 130,199 35" 40,84; 24-0 69,745 22.5 18,26518230'2 403 ‘83‘8 464 50'2 496168‘1 1901 84,113 8,69 73,462 11,2 3 134 46 523 _ Pahang“$1911 118,708 “-1 24,287179-3 87,10918'6 6,611427-6 137 2'2 85 84-8 479 8-4 (Fig. 3, page 2) AXVWNDS HV’IHHVJ, IZI TABLE 3 POPULATION OF FEDERATED MALAY STATES SHOWING DENSITY CENSUS OF 1911 St t Population Area Persons per Acres per a e ‘ 1911 (Sq. Miles) Sq. Mile Person Total .................... 1,036,999 27,506 37.7 16.9 Perak ........................ 494,057 7,800 63 .3 1011 Selangor ..................... 294,035 3,156 93. 2 6.9 Negri Sembilan ............... 130,199 2,550 5111 12. 5 .Pahang ...................... 118,708 14,000 8.5 75.5 (Fig. 4, page 3) ZZI GHVOH HL'IVEIH 'IVNOLLVNHHLNI TABLE 4 POPULATION OF FEDERATED MALAY STATES LIVING ON ESTATES BY RACE Indians Chinese Malays State All Races No. PC. No. P.C. No. P.C. Total ......................... 158,134 94,950 60.0 40,026 25.3 23,158 14.6 Pcrak ............................. 62,257 33,122 53.2 16,403 26.3 12,732 20.5 Selangor .......................... 67,375 49,910 74.1 10,666 15.8 6,799 10.1 Negri Sembilan .................... 26,466 11,257 42.5 12,027 45.4 3,182 12.0 Pahang ........................... 2,036 661 32.5 930 45. 7 445 21.9 (Fig. 5, page 4) AHVWNHS HV’IHEIVL €zI TABLE 5 POPULATION OF FEDERATED MALAY STATES ENGAGED IN PRINCIPAL OCCUPATIONS MALE AND FEMALE Occupation Both Sexes Males Females Total ............................... 670,742 548,829 121,913 Agriculture .............................. 323,065 231,356 91,709 Mining .................................. 163,680 156,327 7,353 Personal service .......................... 25,917 20,932 4,985 Government service ...................... 23,499 22,615 884 Commercial transportation ................ 53,371 52,291 1,080 Miscellaneous ............................ 81,210 65,308 15,902 (Fig. 6, page 5) 1731 GHVOH HL'IVEIH 'IVNOLLVNHHLNI TABLE 6 RESPECTIVE MERITS OF MICROSCOPIC EXAMINATION AND MEDICATION, AS MEANS OF REVEALING HOOKWORM INFECTION BY RACE Persons Found Infected with , Hookworm by Persons Found Infected with Race Examination of Feces for Ova Hookworm by Treatment and Recovery of Worms Expelled No. PC. All Races ...................... 3,776 87.8 872 92.4 Tamils ............................. 2,472 95. 3 261 99 . 6 Chinese ............................. 783 73 . 4 453 90.1 Malays ............................. 206 88.8 97 99.0 Bengalese ........................... 25 8410 2 100.0 Europeans .......................... 23 21.7 .. .... Singalese ............................ 3 100.0 ... A... Javanese ............................ .... ... 1 100.0 Eurasians and mixed races ............ 264 65.9 58 67.2 (Fig. 18, page 22) AHVWWDS HV’IHHVL QzI TABLE 7 RELATIVE ACCURACY OF HOOKWORM DIAGNOSIS BY FECES EXAMINATION, AS INDICATED BY LATER RECOVERY OF WORMS Two HUNDRED NINE CASES TREATED IRRESPECTIVE 0E RESULT or FECAL EXAMINATION Number Per Cent of Total Cases considered ........................................ 209 100.0 Feces positive and treatment positive ........................... 176 ' 84.2 Feces positive and treatment negative .......................... 5 2.4 Feces negative and treatment positive .......................... 17 8.1 Feces negative and treatment negative .......................... 11 5.3 (Fig. 22, page 26) gal GHVOH HL'IVEIH 'IVNOILVNXEILNI TABLE 8 WORMS RECOVERED FROM SEVENTEEN HOOKWORM CASES NEGATIVE BY FECES EXAMINATION, BUT POSITIVE BY TREATMENT Necatora Ancylostomcs Case No. Total Worms IVIale Female Male 1 l 0 0 2 1‘' O O 0 3 l l O 0 4 2 1 l 0 5 l 0 l 0 6 4 3 l 0 7 1 0 l 0 8 2 0 2 0 9 2 0 2 0 10 2 0 2 0 ll 2 0 2 0 12 3 l 2 0 l3 5 2 3 0 l4 8 4 4 0 15 16 10 6 0 16 15 6 9 0 17 22 8 3 1 " Male A. ceylam'cum. AXVNNI'IS HV’IHHVL 2m TABLE 9 COMPARATIVE EFFECT OF THYMOL AND CHENOPODIUM ON TWO SPECIES OF WORMS Thymol Oil of Chenopodium Worms Removed by Worms Removed by Worms Removed by Worms Removed by Entire Treatment Trial Treatment Entire Treatment Trial Treatment Dose Cases Necators Ancylo- Dose Cases Necators 1:35;]:- Neca- Ancylo- stomes Neca- Ancylo- Total Total tors stomes tors stomes No. l’.C. No. P.C. No. P.C. No. RC. 40 grs 65 3,369 3,173 196 ,2,41176.0 5930.1 0.75 mils 10 220 179 41 158 88.3 26 63.4 60 grs 10 202 164 38 157 95.7 22 57.9 1.50 mils 49 2,747 2,491 256 2,422 97. 2 205 80.1 90 grs 19 639 577 62 567 98.3 58 93 .5 3.00 mils 20 460 381 79 379 99.5 76 96. 2 120grs 28 3,324 3,127 197 2,09867.110151.3 .. (Fig. 27, page 32) 8Z1 (IHVOH HL’IVEIH ’IVNOILVNHEILNI TABLE 10 EFFECT OF FULL AND REDUCED DOSAGES OF THYMOL AND OIL OF CHENOPODIUM IN EXPELLING TWO SPECIES OF »WORMS. TRIAL TREATMENT ONLY NINETY—FOUR CASES TREATED WITH THYMOL; 79 waH CHENOPODIUM Percentage Removed of Percentage Removed of Necators Present Ancylostomes Present Dosage By By By By Thymol Chenopodium Thymol Chenopodium Maximum .......................... 98.3 99.5 93 .5 96. 2 Two—thirds maximum ................ 95.7 . . . . 57. 9 .... One-half maximum .................. .... 97.2 .... 80.1 Four-ninths maximum ............... 76.0 .... 30.1 .... One-quarter maximum ............... .... 88,3 .... 63.4 (Fig. 28, page 33) AHVWWI’IS HV'II’IHVL 6ZI TABLE 11 SUPERIOR EFFICACY OF CHENOPODIUM, AS COMPARED TO THYMOL, IN REMOVING MORE RESISTANT WORM SPECIES Dosage Superiority in Efficacy of Oil of Chenopodium In Percentage of In Percentage of Necators Removed Ancylostomes Removed 3.00 mils chenopodium=90 gr. thymol ........................... 1.50 mils ” =60 gr. ........................... 0.75 mils “ =40 gr. “ ........................... 1.2 2.7 1.5 22.2 12.5 33.3 (Fig. 29, page 33) 021 GHVOEI Hl’IVEIH ’IVNOILVNXEILNI TABLE 12 EFFICACY OF VARIOUS VERMICIDES IN EXPELLING HOOKWORMS AND EFFECTING CURE. . THIRTY-EIGHT CASES Worms Removed by Cases Cured by Trial Treatment Drug and Dose Cases Trial Treatment ‘ Entire Treatment No. P.C. No. P.C.* Beta-naphthol, 20 grains, in capsules, two doses with two~hour interval ........... 10 165 44 26.7 0 0.0 Eucalyptus, 30 minims; chloroform, 45 min- ims; and castor oil to 12 drams, divided into two doses of 6 drams each and given at two-hour intervals ................. 10 420 197 46.9 1 10.0 Thymol, 30 grains, in emulsion, two doses with two-hour interval ................ 10 202 179 88. 6 6 60_0 Oil of chenopodium, 1 mil in capsules, two . closes with two-hour interval ........... 8 104 100 96.2 5 62.5 "‘ This column is included merely as an item of interest. The number of cases upon which the percentages are based is too small to make the percentage figures significant. (Fig. 30, page 34) AHVWNOS HV'IIIHVJ. TABLE 13 HOOKWORMS EXPELLED BY TWO TREATMENTS OF SMALLER-THAN-MAXIMUM DOSES OF THYMOL AND CHENOPODIUM. SIXTY—TWO CASES Nccators Ancylostomes Worms Removed by Worms Removed by Drug and Dose Worms Re- Two Trial Treatments Worms Re- Two Trial Treatments moved by moved by Entire Entire Treatment No P C Treatment No P.C. Thymol, two treatments, 40 grains each, 23 cases ................................ 3,173 2,680 84.5 196 96 49.0 Oil of chenopodium, two treatments, 1.5 mils each, 39 cases .................... 2,099 2,091 99.6 167 153 91.6 (Fig. 31, page 35) z‘EI GHVOH HL'IVEI‘H ’IVNOILVNHELLNI OF CHENOPODIUM, AS COMPARED WITH TWO ZO-GRAIN TABLE 14 WORMS EXPELLED AND CASES CURED BY TWO HALF-MAXIMUM—DOSE TREATMENTS TREATMENTS OF THYMOL IN VARIOUS FORMS Worms Removed Cases Cured by Trial Treatments Drug and Dose Cases Trial Treatments Entire Treatment No. P.C. No. P.C.* 1. Two treatments of oil of chenopodium, 0.5 mils in capsules, three times at hourly intervals ................... 39 2,266 2,244 99.0 27 69. 2 2. Two treatments of thymol in capsules, 20 grains twice with two hours' intervals 23 2,032 1,695 83.4 6 26.1 3. Two treatments of thymol, 20 grains in capsules, with lactose, 20 grains; two doses with two hours' interval ...... 10 887 704 79.4 3 30.0 4. Two treatments of thymol, 20 grains ground to fine powder twice with two hours’ interval .................... 10 67 54 806 3 30.0 5. Two treatments of thymol, 20 grains, and lactose, 20 grains, ground to fine pow- der; two doses with two hours' interval 18 383 323 84.3 6 33 .3 * See Table 12. (Fig. 32, page 35) AHVNWHS HV'IHHVL I WORMS EXPELLED AND CASES CURED BY CHENOPODIUM IN VARIOUS DOSES TABLE 15 SINGLE TRIAL TREATMENT Dose Cases Worms Removed Entire Trial Treatment Cases Cured by Trial Treatment Treatment No. P.C. No. RC.“ . Oil of chenopodium, 1 mil in capsule; three doses at hourly intervals, or 3 mils . Oil of chenopodium, 1 mil in capsule; two doses with two hours’ interval, or 2 mils .............................. . Oil of chenopodium, 2 mils in capsules; one dose only, 2 mils ............... . Oil of chenopodium, 0.5 mils in capsule; three doses at hourly intervals, or 1.5 mils .............................. . Oil of chenopodium, 0.5 mils in liquid paraffin, % 02.; three doses at hourly intervals, or 1.5 mils ................ . Oil of chenopodium, 0.25 mils in cap- sule; three doses at hourly intervals, or 0.75 mils .......................... . Oil of chenopodium, 10 minims, or just over 0.5 mils, in X’s gelatine capsules; three doses at hourly intervals, or 30 minims ............................ . Oil of chenopodium, extracted from X's gelatine capsules, 0.5 mils, in freshly filled capsule, three doses at hourly intervals, or 1.5 mils ................ 17 30 10 10 10 460 - 104 545 481 275 230 107 95 455 100 522 459 244 184 71 93 98.9 96.2 95.8 80.0 66.4 97.9 14 21 2 82.4 62.5 70.0 40.0 40.0 50.0 “ See Table 12. (Fig. 33, page 36) 1791 GHVOH HL'IVEIH ’"IVNOILVNHELLNI TABLE 16 WORMS EXPELLED AND CASES CURED BY THYMOL IN LARGE DOSES SINGLE TRIAL TREATMENT Worms Removed ' Cases Cured by Trial Treatment Dose Cases Trial Treatment Entire Treatment No. P.C. No. P.C.* Thymol, 30 grains, in powder, three times, AHVWWHS HV’IDHVL or 90 grains .......................... 19 639 625 97.8 14 73.7 Thymol, 40 grains, in powder, three times, or 120 grains ........................ 19 2,384 1,292 54.2 8 42.1 Thymol, 1 dram, in powder, three times, or 180 grains ........................ 9 940 907 96.5 6 66.7 *See Table 12. (Fig. 34, page 37) 991 TABLE 17 SUMMARY OF RELATIVE VALUES OF THYMOL AND OIL OF CHENOPODIUM IN TREATING HOOKWORM DISEASE Thymol Oil of Chenopodium . The 90-grain dose produced a very satisfactory re- moval of worms. . Higher doses, for example 120 grains, removed fewer worms because the vomiting that occurred reduced the amount of drug retained in the stomach to be- low the amount required for efiicient removal of worms; but with 180 grains, though much vomiting occurred, the amount of the drug retained was still sufficient to effect a satisfactory removal of worms. . No serious toxic symptoms were noted even with the highest dose. . No serious toxic symptoms were noted even with the highest dose. . Diminution of the dosage produced a rapid falling ofl’ of efficiency. . Two treatments with a small dose did not produce a good summation of results. . The highest dose (i. 1. Three mils produced the largest vermifugal effect of any single treatment tried, but the result was only slightly superior to the corresponding dose of thyme]. . The dose at which the vomiting caused loss of effi- ciency was not reached at one institution, al- though 3 mils were given. At another, 46. 9 per cent of vomiting occurred with loss of efficiency at the dosage of 15 minims three times, or 2.8 mils. e, 3 mils) occasionally pro- duced tox1c effects on the nervous system, such as nerve deafness and coma. . In the lower doses, 1.5 mils and under, no deafness or coma occurred. . The efliciency was well maintained when the dose was reduced even down to a quarter of the maxi- mum dose. . Two half-maximum doses produced a better result than the full maximum dose, and the highest percentage of worms removed was obtained by this treatment, i. e., 99.6 per cent of Necators and 97.5 per cent of Ancylostomes. (Concluded next page) 991 GHVOH HL’IVEIH 'IVNOILVNHEILNI TABLE 17 (concluded) Thymol Oil of Chenopodium 10. 11. 12. . Thymol was voted, by a great majority of the patients treated, as more unpleasant to take than oil of che- nopodium. . The characteristics noted under 5, 6, and 7 render thymol less suitable for use in the treatment of children than oil of chenopodium, as for children the smaller dose would be required. . The effect on the more resistant forms of worms has been shown to be less, dose for dose, with thymol than with oil of chenopodium. Thymol, being a relatively insoluble powder, has less opportunity than chenopodium of becoming uni— formly distributed throughout the intestinal con- tents. According to consideration No. 10, the action of thymol was less uniform than that of chenopodium, and there were 23.6 per cent of cases in which relative failure of the treatment occurred. Thymol removes a certain proportion of the worms of species other than hookworms. 9. This renders chenopodium as the drug for choice in treating Chinese, West Indians, or any other people with a high percentage of ancylostomes. 10. Chenopodium, being a thin oil, will become more evenly diffused along the intestine. 11. Only 7.6 per cent of the patients treated with chen0< podium showed relative failure of treatment. 12. Oil of chenopodium has been shown to be more effect- ive than thymol in removing all the other species. AHVWWHS HV'IIIHVL LEI TABLE 18 COST OF THYMOL AND CHENOPODIUM, WITH COMPARATIVE EFFICACY BASED ON WORMS EXPELLED Percentage Removed of Total Drug and Dose Cost Worms Present Thymol Chenopodium Oil of Oil of in grains ’ in mils Thymol Chenopodium Thymol Chenopodium 40 0.75 50.06 $0.014 73.3 80.0 60 1.5 0.09 0.028 88.6 95.7 90 3.0 0.135 0.055 97.8 98.9 (Fig. 35, page 37) 3‘81 (DIVOH HJ/‘IVHH 'IVNOLLVNEIEILNI TABLE 19 AFTER-EFFECTS OF THYMOL AND CHENOPODIUM‘ Symptom Thymol Oil of Chenopodium . Dizziness ........... Frequently noted More common . Muscular inco—ordina- tion .............. Noted More marked . Inability to rise ...... Noted Much more frequent . Semi-comatose state (further stage of 2| and 3) ............ Not noted Only rarely noted . Burning in stomach. , Much more marked Noted . Headache ........... More marked Noted . Tingling of the hands and feet .......... None Noted . Vomiting ........... Dose Cases Cases Per Cent Dose Cases Cases Per Cent Gr. Treated Vomited Vomited mils Treated Vomited Vomited 40 65 4 6.2 075 10 0 0.0 60 10 0 0.0 1.5 49 6 12.2 90 19 3 15.8 3.0 20 3 15.0 120 19 11 57.9 130 10 5 50.0 Total 123 23 18 i 7“ Total 79 9 11 . 4” (Concluded next page) HV'IQHVI. AHVNWL’IS 621 TABLE 19 (concluded) Symptom Thymol Oil of Chenopodium 9. Albuminuria ........ Origin Origin . Per . P" Dose Exam- P051- Cent Dose Exam- Posn- Cent N Gr. ined tive Posi- N“ mils ined tive Posi- .Ot . ’ Renal Gonor- Diag- tive Renal Gonor— Diag- tne rheal nosed rhea] nosed 40 50 6 12.0 2 4 1‘5 52 7 13.5 .l .. 7 3‘0 39 8 20.5 1 4 3 10. Deafness ............ Not Noted Cases of Deafness Total D958 Number "“13 Treatments Number Per Cent 1.5 000 0 0.0 3.0 446 5 1.1 11. Deaths ............. None Two, after two treatments of 3 mils administered with only a four—day interval * Figures cover 123 cases treated with thymol in doses ranging from 40 to 180 grains, ranging from 0.75 to 3.0 mils. . ** The excess of total cases with vomiting after thymol as compared to those treated with chenopodium may be attributed mainly to the administration to twenty-nine patients, and 79 cases treated with oil of chenopodium in doses in the case of thymol, of doses that exceeded the limit of tolerance. (Figs. 36, 37, 38, and 39, pages 38 to 41) 0171 GHVOH HL’IVEIH HVNOILVNHHLNI TABLE 20 EXPERIMENTS WITH VARIOUS PURGES IN CHENOPODIUM TREATMENT Worms Removed Cases Cured by Trial Treatment Drug and Dose Cases Trial Treatment Entire Treatment No. P.C. No. P.C.* Compound mixture of senna, 2 ounces ..... 6 29 22 75.9 3 50.0 Castor oil, 1% ounces .................... 9 97 79 81.4 4 44.4 Magnesium sulphate, 1 ounce ............ 10 107 71 66.4 6 60.0 Calomel, 4 grains, and magnesium sulphate, 1 ounce .............................. 6 62 50 80. 6 3 50. 0 * See Table 12. , (Fig. 40, page 42) AHVWNIIS HV'IHHVJ. 1h TABLE 21 RESULTS OBTAINED BY VARYING DIET AND OMITTING INITIAL PURGE 3171 IN TREATING HOOKWORM DISEASE WITH CHENOPODIUM With Purge Without Purge Worms Removed Worms Removed Diet Cases Trial Treatment Cases Trial Treatment Entire Entire Treatment Treatment No. P.C. No. P.C. Diet 1: Full diet all through the treatment ................... 5 220 98 44.5 5 42 24 57.1 Diet 2: Full diet all the day pre- vious to treatment, but milk on the morning of the treatment. . 4 97 86 88.7 4 64 56 87. 5 Diet 3: Rice gruel (kunji) on the afternoon previous to treat- ment, but milk on the morning of treatment ................ 4 50 46 92.0 5 46 44 95.7 Diet 4: Only milk during the day previous to treatment, and only milk on the morning of treatment ................... 12 202 159 78.7 14 616 347 56.3 CIIIVOEI HL’IVEIH ’IVNOILVNHELLNI (Fig. 41, page 42) TABLE 22 RESULTS OF EXAMINATIONS FOR HOOKWORM DISEASE AT PORT .SWETTENHAM Persons Examined Persons Positive Per Cent Positive Total ............................... 2,262 Men .................................... 1,736 Women ................................. ‘ 384 Children 12 years and under .............. 142 2,188 1,696 371 121 96.7 97.7 96.6 85.2 (Fig. 48, page 47) AHVWWL’IS ZIV'II'IEIVL £171 TABLE 23 HOOKWORM INFECTION RATES, BY AGE GROUPS, FOR CHILDREN LESS‘ THAN TWELVE YEARS OLD. MISCROSCOPIC EXAMINATIONS AT PORT SWETTENHAM Age Group Examined Positive Per Cent Positive All ages less than twelve ............ 142 121 85.2 1 year or less ........................... 3 0 0.0 1 and 2 years ........................... 6 4 66.7 3—4 “ ........................... 21 16 76. 2 5—7 “ ........................... 36 31 86. 1 8—10 “ ........................... 44 40 90.9 11-12 “ ........................... 32 30 93 . 8 (Fig. 49, page 48) W1 (DIVOH Hl’IVEII-I ’IVNOILVNHEILNI TABLE 24 VULNERABILITY OF WORMS TO VERMICIDE, BY SPECIES AND SEX BASED ON SAME DATA AS TABLE 24A. PERCENTAGE REMOVED BY FIRST AND SUBSEQUENT TREATMENTS, ASSUMING AS 100% THE TOTAL NUMBER OF WORMS ORIGINALLY HARBORED, OF ALL SPECIES AND SEXES, IRRESPECTIVE OF NUMBER HARBORED AT THE TIME or TREATMENT Species Necators Ancylostomes Total, Vggxrms ; E E Worms ‘- . Removed é) Necators ADC) 10— Male Female Male Female Male Female g _ stomes 7:! (3 ‘4 U2 [—10 No. P.C. No. P.C. No. P.C. No. P.C. No. P.C. No. P.C. No. P.C. No. P.C. E E Entire Treat- pa ment ...... 4,553 3,998 100.0 555 100.0 2,017100.0 1,981 100.0 242 100.0 313100.0 2,259 100.0 2,294 100.0 '< lst treatment 4,296 3,871 96.8 425 76.6 1,976 98.0 1,895 95.7 223 92.1202 64.5 2,199 97. 3 2,097 91.4 2d ” 217 108 2.7 109 19.6 38 1.9 70 3.5 16 6.6 93 29.7 54 2.4 163 7.1 3d “ 39 19 0.5 20 3.6 3 0.1 16 0.8 3 1.2 17 5.4 6 0.3 33 1.4 4th “ 1 0 l 0.2 .. 1 0.3 .. l*0.l * Less than one-tenth of one per cent. (Fig. 50, page 48) H 4; UI WORMS HARBORED, OF EACH SPECIES AND SEx, AT THE TIME OF EACH TREATMENT TABLE 24A VULNERABILITY OF WORMS TO VERMICIDE, BY SPECIES AND SEX PERCENTAGE REMOVED BY FIRST AND SUBSEQUENT TREATMENTS, ASSUMING As 100% THE TOTAL NUMBER OF Worms Removed Necators Ancylostomes Treatments Total Necators AnCy10< Total Males Females TO' Males Females stomes ta] All Treatments 4,553 3,998 87.8 555 12. 2 3,998 2,015 50.4 1,983 49 , 6 555 242 43. 6 313 56.4 First Treatment 4,296 3,87190.1 425 9.9 3,871 1,974 51.0 1,897 49.0 425 223 52.5 202 47.5 Second “ 217 108 49. 8 109 50.2 108 38 35.2 70 64. 8 109 16 14.7 93 85.3 Third “ 39 1948.7 20 51.3 19 315.8 16 84.2 20 3 15.0 17 85.0 Fourth “ 1 .. .. 1100.0 .. .. l... 1100.0 9171 (IHVOEI HI’IVEIH 'IVNOILVNHE-ILNI TABLE 25 EFFECT ON NECATORS AND ANCYLOSTOMES OF VARYING DOSAGES OI" CHENOPODIUM SINGLE TRIAL TREATMENT Species and Sex of Worm Percentage Removed of Total Worms Present 2 mils and over 1.5 mils and under Difference between Effect of Higher and Lower Dose Necators, male .......................... Necators, female ......................... Ancylostomes, male ...................... Ancylostomes, female ..................... Percentage difference between the most and the least resistant worm classes ........... 99.6 97.4 98.4 94.9 95.9 90.5 78.3 58.8 21.3 38.6 \OU'IWN mfiU'IN (Fig. 51, page 49) AHVNWDS XV’IIIHVJ. TABLE 26 EFFECT ON NECATORS AND ANCYIDSTOMES OF VARYING DOSAGES OF THYMOL SINGLE TRIAL TREATMENT Species and Sex of Worm Percentage Removed of Total Worms Present Difference between Effect of Higher and Lower Dose 90 gr. 60 gr. and under Necators, male .......................... 99.0 80.0 19.0 Necators, female ........................ 97.4 73.7 23.7 Ancylostomes, male ...................... 92.6 30.9 61.7 Ancylostomes, female .................... 94.3 37.9 56. 4- Percentage difference between the most and the least resistant worm classes ........... 4. 7 42 .1 (Fig. 51, page 49) 8h GHVOH HL'IVEIH 'IVNOILVNHHLNI DIFFICULTY OF EXPELLING WORMS WHEN TABLE 27 NUMBER HARBORED IS SMALL PERCENTAGE REMOVED BY FIRST TREATMENT, WHEN NUMBER OF WORMS HAREORED Is LARGE, COMPARED WITII PERCENTAGE REMOVED BY SECOND TREATMENT, WHEN NUMBER HARBORED Is CORRESPONDINGLY SMALLER. CHENOPODIUM AND VARIOUS DOSAGES 0F THYMOL EMPLOYED First Treatment Second Treatment Drug and Dose Total Total Worms Percent- Worms Worms Percent- Worms R d age Left After R _ d age Present emove Removed First emovc Removed Treatment All drugs and all dosages employed 5,636 4,639 82.3 997 372 37.3 Oil of chenopodium, 0.5 mils, three times. . .. 2,266 2,168 95.7 98 76 77.6 Thymol, 20 grains twice in capsules ....... 2,033 1,586 78.0 447 100 22.4 Thymol, 20 grains twice in capsules and sugar of milk .............................. 887 548 61.8 339 156 46.0 Thymol, 20 grains twice in powder ........ 67 53 79.1 14 1 7.1 Thymol, 20 grains twice in powder, with sugar of milk .............................. 383 284 74.2 99 39 39.4 (Fig. 52, page 50) AHVNWHS HV’IHHVJ. 6171 TABLE 28 AVERAGE HEMOGLOBIN AND AVERAGE NUMBER OF HOOKWORMS HARBORED BY EIGHTY-EIGHT CHINESE TREATED AT SINGAPORE, BY SEX AND AGE CASES WITH No PREVIOUS RESIDENCE OTHER THAN CHINA COMPARED WITH CASES HAVING OTHER PREVIOUS RESIDENCE Cases with No Evidence of Former Residence Cases with Evidence of Former Residence Percent~ Other Than China Other Than China age of Average Seéor Age Cases Hook— Hemo- roup worm In- globin Average _ Average fection Average Hook- Average Hook- Number HemO- Number Hemo- globin “WC” globin “”15 per ase per Case Total.... 88 88.6 74.9 60 75.1 31.5 28 74.5 20.0 Men ......... 62 90.3 77.5 50 77.8 32.3 12 76.3 23.7 Women ...... 20 85.0 65.5 7 55.6 34.9 13 70.8 19.0 Children ..... 6 79.5 3 75.7 10.3 3 83.3 10.0 83.3 (Fig. 53, page 52) OS‘I GHVOH HL'IVEIH 'IVNOLLVNEIEILNI RESULTS OF EXAMINATION FOR HOOKWORM TABLE 29 DISEASE IN FIJI ISLANDS Race, Sex, or Age Group Examined Infected Per Cent Infected Total ............................... 190 183 96.3 Indians: Men ................................. 131 131 Women ............................... 11 10 Children .............................. 2 2 Fijians: Men ................................. 20 20 Women ............................... 4 4 Children .............................. 9 9 Half-castes: Adults ................................ l 0 Children .............................. 7 5 European Children ....................... 5 2 AHVWWHS HV'IHHVL 191 391 TABLE 30 HOOKWORM-SPECIES FORMULA ACCORDING TO RACE, OCCUPATION, ENVIRONMENT, ETC. Ancylo‘ stome Average Average Index, 0|. Special Considerations such as . Total No. Of No. of 50‘ 0f Proportion Race N°~ 0f Condition, Occupation, nviron— Native H001“ H001“ Ancylo- Ancy 10' of Ancylo— Persons ment etc. Place worms worms stomes stomes stomes to ’ Removed Per Per Total Hook- Person Person worms Harbors-d Malay 38 School boys, Kam ong Bharu Malaya. K.L. 2,262 59.5 5 0.13 0.2 Malay 39 School boys, Ulu ombak Malaya, Ulu Gombak 1,559 40.0 13 0.33 0.8 Malay 16 Mala s, 13 males and 3 females born in F erated Malay States Malaya 1,138 71. 1 10 0.63 0.9 Malay 12 Malays born in Java, location unknown Java 1,757 146.4 46 3.83 2.6 Malay 28 Malays born in Sumatra Sumatra 2,746 98. 1 58 2.07 2. l Malay 12 Malays born in Sumatra. Jail Series, Batavia Sumatra 919 76. 6 7 0.58 0 . 8 Malay 83 Malays, Batavia Kam ongs West Java 2,935 35.4 26 0.31 0.9 Malay 25 Sudanese, Preanger, ampong Endil Preanger. J ava 1,275 51.0 2 0.08 0.2 Malay 25 Sudanese, Preanger, Tjimatjan Preanger, Java 150 6.0 0 0.00 00 Chinese 2 Straits-born Chinese Malacca. SS. 72 36.0 0 0.00 0.0 Chinese 1 Batavia-born Chinese Batavia 123 123.0 1 l .00 0.8 Malay 4 Celebes, Jail Series, Batavia Celebes 523 130.8 0 0.00 0.0 Tamils ? From Madras, India. Worms Recov- ered from Treatments South India 10.455 ? 312 ? 3.0 Tamils 34 Treatments, Tamils recently from Madras South India 4.363 128.3 89 2.62 2.0 Malabaris 25 Patients, Hospital No.1.ch.Malay States South India 3,491 139.6 30 1 . 20 0.9 Enigma d 35 Road Coolies, Federated Malay States South India 2,870 82.0 59 1.69 2.1 i s an Pathans 13 Police. Federated Malay States North India 124 9.5 86 6.62 69.4 CIHVOEI HITVEIH "IVNOILVNHEILNI TABLE 30 (concluded) Ancylo- stome , Average Average Index, or Special Considerations, such as . Total No. Of No. of No. 0‘ Proportion Race No. Of Condition, Occupation, Environ- Native H001" H001" Ancylo- Ancylo- of Ancylo— Persons ment, etc. Place worms worms stomes stomes stomes to Removed Per Per Total Hook- Person Person worms Harbored Chinese 5 Fatal cases of severe hookworm disease (post mortem records) South China 4,387 877.4 3,779 755.80 86. 1 Chinese 46 Newcomers from China, “Sinkehs” South China 1,241 27.0 420 9.13 33.8 Chinese 79 Patients, Hospital No. l, F.M.S. South China 5,191 65.7 1,994 25.24 38.4 Chinese 13 Estate Coolies, Sumatra, Jail Batavia South China 838 64 . 5 255 19.62 30.4 Malays 2 Sumatra Malays, probably infected from Chinese sources Sumatra 38 19.0 25 12.50 65.8 Tamils 57 Night-soil Coolies, F.M.S., infected from Chinese South India 7,259 127.4 806 14 .14 11.1 Tamils 118 Patients, District Hospital, infected from 'nese South India 12,806 108.5 658 5.58 5.1 Javanese 50 Java, Gebongelir, Kampongs Mid-Java 2.339 46.8 308 6.16 13.2 Javanese 24 Java, Kalimaro, Kampongs Mid-Java 5,140 214.2 322 13.42 6.3 Javanese 25 Java, Kebasekan, Kampongs Mid-Java 4.082 163.3 219 8 . 76 5.4 Javanese 28 Java, Krakal-Karangsari, Kampongs Mid—Java 10,861 387.9 770 27.50 7.1 Javanese 9 Prisoners, Batavia Jail Mid- and East Java 755 83.9 57 6.33 7.5 Madurese 16 Prisoners, Batavia Jail Madura 1,263 78.9 173 10.81 13.7 Balinese 5 Prisoners, Batavia Jail Bali 348 69.6 14 2.80 4.0 Timorcse 4 Prisoners, Batavia Jail Timor 100 25.0 61 15.25 61.0 Lombokans 4 Prisoners, Batavia Jail Lombok 479 119.8 16 4.00 3.3 Chinese 1 Chinese born in Mid-Java, Semarang Mid—Java 57 57.0 11 11.00 19.3 (Fig. 54, page 54) AHVWWHS HV’IHEIVL €91 TABLE 31 RESULTS OF FECAL EXAMINATIONS FOR HOOKWORM DISEASE AND BLOOD EXAMINATIONS FOR MALARIA, DISTRICT HOSPITAL AT KUALA LUMPUR CLASSIFICATION BY RACES Hookworm Ova Malaria Parasites Race No. No. PC. No. No. P.C. Examined Positive Positive Examined Positive Positive All Races ............. 524 399 76.1 588 208 35.4 Chinese .................... 323 246 76.2 363 90 24.8 Tamils ..................... 173 130 75.1 191 105 55.0 Bengalese .................. 24 20 83 .3 3O 11 36. 7 Singalese ................... 3 3 100.0 3 1 33.3 Japanese ................... l ... 0.0 I 1 100.0 (Fig. 57, page 65) #91 GXVOEI Hl’IVEII-I 'IVNOIIVNHEILNI RATES OF MALARIA AND HOOKWORM INFECTION AMONG CHINESE, TAMIL, TABLE 32 AND BENGALESE PATIENTS. FIVE HUNDRED TWENTY—TWO CASES AT DISTRICT HOSPITAL, KUALA LUMPUR All Races Chinese Tamils Bengalese No. of No. of No. of No. of Cases P' 0 Cases P' 0 Cases P' C' Cases 13' C' All Races; positive and negative. . 522 . . . 328 170 24 Positive to Hookworm; Total ........ 395 75.7 249 75 .9 126 74.1 20 83 .3 Positive to Hookworm; Positive to Malaria ......................... 133 25.5 58 17.7 68 40.1 7 29.1 Positive to Hookworm; Negative to Malaria ......................... 262 50.2 191 58.2 58 34.1 13 54.2 Negative to Hookworm; Total ....... 127 24.3 79 24.1 44 25 .9 4 16. 7 Negative to Hookworm; Positive to Malaria ......................... 51 9.8 23 7.0 27 15.9 1 4.2 Negative to Hookworm; Negative to Malaria ......................... 76 14.6 56 17.1 17 10.0 3 12.5 Positive to Malaria; Total ........... 184 35 .2 81 24. 7 95 55.9 8 33 .3 Positive to Malaria; Positive to Hook- worm ........................... 133 25.5 58 17.7 68 40.0 7 29.1 Positive to Malaria; Negative to Hook— worm ........................... 51 9.8 23 7.0 27 15.9 1 4.2 Negative to Malaria; Total .......... 338 64. 8 247 75 .3 75 44.1 16 66.7 Negative to 1\/Ialaria; Positive to Hook- worm ........................... 262 50.2 191 58.2 58 34.1 13 54.2 Negative to Malaria; Negative to Hookworm ...................... 76 14.6 56 17.1 17 10.0 3 12.5 (Fig. 58, page 66) AHVWNIIS HV’IQHVJ. 991 TABLE 33 CORRELATION BETWEEN INTENSITY OF ENLARGED SPLEENS AND PREVIOUS RESIDENCE SPLEEN EXAMINATIONS or Cooues ENTERING AT PORT SWE'ITENHAM Previous Residence CIHVOEI Hl’IVElH 'IVNOILVNHEILNI . . All Previous Spleen Condition Residences Federated . Other India Malay C t ' 0 1 States oun nes n y Total Cases ................................ 2,261 437 98 1,726 Enlarged spleens ............................ 130 59 11 60 Percentage of enlarged spleens ................ 5.7 13.5 11.2 3.5 Enlarged spleens classified: a. Palpable ............................... 69 27 7 35 b. One finger’s breadth .................... 28 12 1 15 c. Two fingers’ “ .................... 23 15 1 7 d. Three fingers’ ” .................... 6 3 0 3 c. Hand's breadth ......................... 2 1 1 0 f. Below the umbilicus ..................... 2 1 1 0 (Fig. 59, page 66) 991 OI TABLE 34 CORRELATION BETWEEN MALARIA PLASMODIA AND FORMER RESIDENCE, SPLENIC CONDITION, AND AGE OF PATIENT BLOOD EXAMINATIONS or Coouzs ENTERING AT PORT SWETTENHAM, 1915—1916 Findings in 1915 Number Percentage Previous Residence, Splenic Condition, and Age Examined Positive for Plasmodia Total ................................................... 336 6.8 Federated Malay States ....................................... 124 9. 7 India only .......... _ ......................................... 189 5.2 Other countries: Total ....................................... 23 4.3 (a) Straits Settlements ...................................... 4 25.0 (b) Ceylon ................................................ 16 0.0 (c) Natal .................................................. 2 0.0 (d) Rangoon ............................................... I 0.0 Spleen enlarged .............................................. 100 14.0 Spleen not enlarged ........................................... 236 3.8 Children 12 years and under .................................. 110 1.8 Adults ...................................................... 226 9.2 (Concluded next page) (Fig. 60, page 67) AHVIAIIAIIIS HV’IIIHVL LSI TABLE 34 (concluded) Findings in 1916 89I N ber Percentage Previous Residence, Splenic Condition, and Age E urnn d Positive for “n" e Plasmodia Total .......... ' ........................................ 250 4.8 Children 12 years and under ................................... 78 2.6 Adults ...................................................... 172 5.8 Former residence India only ................................... 204 3.4 Former residence other than India .............................. 46 10.9 (a) Federated Malay States .................................. 40 12.5 (b) Ceylon ................................................ 3 0.0 (c) Singapore .............................................. 1 0.0 (d) Malacca ............................................... l 0.0 (e) Johore ................................................. 1 0.0 GHVOH HL’IVHH ’IVNOILVNHEILNI TABLE 35 HEMOGLOBIN OF COOLIES WHO HAD PREVIOUSLY LEFT INDIA COMPARED WITH HEMOGLOBIN OF THOSE WHO HAD NOT TWENTY-TWO HUNDRED TWENTY-FIVE COOLIES EXAMINED FOR MALARIA AT Pox-r SWETTENHAM - - Coolies Without Record of Coolies With Record of Wifliflitvgégoga Previous Emigration Previous Emigration Hemoglobin Rate (1); P_revious migration Percentage Percenta e from India No. of Total No. of Totalg Total .......................... 2,225 l ,690 76 . 0 535 24 . 0 100—110 ............................ 32 23 71.9 9 28.1 90-99 ............................. 213 159 74.6 54 25.4 80—89 ............................. 731 571 78.1 160 21.9 70-79 ............................. 692 535 77.3 157 22.7 60—69 ............................. I65 120 72. 7 45 27. 3 50-59 ................ - ............. 213 159 74.6 54 25. 4 40—49 ............................. 112 84 75.0 ' 28 25.0 30—39 ............................. 44 27 61.4 17 38.6 20—29 ............................. l4 9 64.3 5 35. 7 10—19 ............................. 5 2 40.0 3 60.0 0—9 .............................. 4 1 25.0 3 75.0 AHVWWHS HV'IDHVL 691 TABLE 36 CORRELATION BETWEEN HEMOGLOBIN RATE AND SIZE OF ENLARGED SPLEEN TWENTY—T\VO HUNDRED TWENTY-FIVE COOLIES EXAMINED FOR MALARIA ENTERING AT PORT SWET'I‘ENHAM Coolies with Classification of Enlarged Spleens Hemoglobin goalies Enlarged Spleens Rate zxam- med Percentage Hand’s Below the N“ of Total Pa‘Pabl" 1 fl" 2 fl” 3 fl" Breadth Umbilicus Totals ....... 2,225 130 5. 8 69 28 23 6 2 2 100—110 .......... 32 2 6.3 l 1 .. .. .. .. 90—99 ........... 213 9 4. 2 7 1 1 . . . . . . 80—89 ........... 731 21 2.9 13 6 1 .. l .. 70—79 ........... 692 32 4.6 20 7 4 .. 1 . . 60—69 ........... 165 11 6. 7 S 2 3 1 . . . . 50—59 ........... 213 19 8.9 7 3 6 2 1 40-49 ........... 112 19 17.0 7 S 6 1 . . 30—39 ........... 44 11 25 .0 5 2 l 2 1 20—29 ........... 14 2 14.3 1 . . 1 . . . . 10—19 ........... 5 2 40.0 1 1 . . 0-9 ............ 4 2 50. 0 2 . . (Fig. 61, page 68) 091 (DIVOH HL'IVEIH 'IVNOILVNHEIINI TABLE 37 GAIN OR LOSS IN HEMOGLOBIN AFTER RESIDENCE ON ESTATES RESULTS OF RE-EXAMINATION, ON ESTATES, OF TWO HUNDRED THIRTY-FOUR CoouEs FOUND FREE OF MALARIA BUT INFECTED WITH Hooxwomu DISEASE ON ARRIVAL AT PORT SWETTENHAM Cases with Signs of Malaria after Residence on Estates Cases with No Sign of Malaria after Residence on Estates Treated at Port N at Treated at Port Treated at Port Not Treated at Port Number Swettenham Swettenham Swettenham Swettenham Estate of Coolica Total Average Total Average Total Average Total Average N0..of Change Chiannge Nozof Chiagme Change No._oi Chiannge Chfifge N0._of Change Change Coolies Hemo— Hemo— 0001193 Hemo— Hemo— 0001193 Hemo— Hemo— 0001195 Hemo— Hemo- globin globin globin globin globin globin globin globin Total .......... 234 28 —159 —5. 7 44 -457 —- 10. 4 41 +624 +15 . 2 121 +730 +6 . 0 In flat country :— Eatnte No. 1 ..... 10 .. .. A . . . 1 +10 +10.0 4 +55 +138 5 +45 +9.0 ” " 2 ..... 20 .. .. 2 +25 +12.5 18 +183 +10.2 " ” 3 ..... 20 1 +28 +28.0 6 —90 —15.0 2 +5 +2.5 11 +146 +13.3 “ " 4 ..... 33 .. .. .. 7 +230 +32.9 26 +35 +14 “ " 5 ..... 21 l 0 0.0 2 +5 +2.5 2 +50 +25.0 16 +15 +0.9 Undulating and hilly country:— Estate No. (i ..... 6 . . . . . . . . 1 +5 +5.0 2 +20 +10.0 3 +45 +15.0 “ “ 7 ..... 23 5 +11 +2.2 1 0 0.0 6 +99 +16.5 11 +74 +6.7 " " 8 ..... 13 1 +16 +16.0 4 —2 —0.5 .. .. 8 +105 +13.l " " 9 ..... ll 2 —8 —4.0 3 +25 +8.3 2 +3 +1.5 4 —14 —3.5 ” “ 10 ..... 12 1 —5 —5.0 2 +5 +2.5 3 +5 +1.7 6 +30 +5.0 " “ 11 ..... 26 6 —41 —b.8 6 —67 —ll.2 8 +104 +13.0 6 +36 +6.0 " “ l2 ..... 19 3 +68 +22.6 8 —92 —11.5 1 +3 +3.0 7 +30 +4.3 ', " l3 ..... 8 5 —l25 —25.0 1 —40 —40.0 2 +25 +12.5 .. " “ 14 ..... 12 3 —103 —34.3 9 —216 —24.0 . . . . . . (Fig. 62, page 70) AHVWWQS HV’IHHVI. 191 TABLE 38 GAIN OR LOSS IN HEMOGLOBIN AFTER RESIDENCE ON ESTATES RESULTS or RPS-EXAMINATION, ON ESTATES, 0F NINETEEN COOLIES FOUND INFECTED WITH MALARIA 0N ARRIVAL AT PORT SWETTENHAM Eflect of Subsequent Malaria Efiect of Hookworm Treatment Cases with Evidence of Malaria at Port Swetten- ham as well as on Estate Cases without Evidence of Malaria on Estate Cases Treated at Port Swettenham (338% Not Treated at Port Swettenham Number Estate ot_ 0001“” Change in Change in Change in Change in Hemoglobin Hemoglobin Hemoglobin Hemoglobln No. of No. of No. of No. of Coolies Cooliea Cooliea Coolies Total Average Total Average Total Average Total Average Change Change Change Change Change Change Change Change Total .......... 19 12 +127 +101) 7 +116 +161) 5 +79 +15.8 14 +164 +11.7 On flat country :— Estate No. l ..... 3 1 +15 +15.0 2 +40 +20 .. . . ... 3 +55 +18.3 " " 3 ..... 1 —-30 —30.0 .. 1 —30 —30.0 .1 " “ 4 ..... l . . . . . . l 0 0 . . . . 4 . . 1 O 0 Undulating and hilly country:— Estnte No. 7 ..... l 1 +31 +31.0 . . . . . . . . . . 1 +31 +31 “ “ 8 ..... 1 .. 1 —8 —8 .. . 1 -—8 —-8 " U 9 ..... 1 1 +25 +25.0 .. .. 1 +25 +25 “ ” 10 ..... 2 2 +35 +17.5 .. .. 2 +35 +17.5 " “ 11 ..... 4 1 —7 —7.0 3 +84 +28 2 +79 +39. 2 —2 —1 " ” 12 ..... 2 2 +23 +11.5 1 +15 +15.0 1 +8 +8 " " 13 ..... 1 1 +15 +15.0 1 +15 +15.0 t. " " 14 ..... 2 2 +20 +10.0 . . . . . 2 +20 +10 (Fig. 62. page 70) 7,9 (IHVOEI HL'IVEIH ’IVNOLLVNHEILNI TABLE 39 GAIN OR LOSS IN HEMOGLOBIN AFTER RESIDENCE ON ESTATES RESULTS OF RE-EXAMINATION, on ESTATES, OF TWELVE COOLIES FOUND FREE OF MALARIA AND HOOKWORM DISEASE ON ARRIVAL AT PORT SWETTENHAM Caseséljgzilqlgggctletrz’cigrfixflaria Cases without Evidence of Malaria Estate No. Of Chan ein Hemo lobin Chan e in Hemo lob' Coolies g g g g m No. of No. of commas Total Average COOIICS Total Average Change Change Change Change Total ................... 12 7 ——110 —15.7 5 —8 —l.6 In flat country:— Estate No.3 ............... 8 3 —87 —29.0 5 —8 —1.6 In hilly, undulating country :_ Estate No. 8 .............. 1 1 —8 —8 .0 “ “ 12 .............. 1 l — 15 ~15 .0 “ ” l3 .............. 2 2 0 0 .0 (Fig. 65, page 73) AHVNWDS HV'IIIEIVJ. €91 TABLE 40 CORRESPONDENCE BETWEEN MALARIA AND GAIN OR LOSS IN HEMOGLOBIN AFTER RESIDENCE ON ESTATES RESULTS OE REE-EXAMINATION, 0N ESTATES, OF 267 CoouEs PREVIOUSLY EXAMINED AT PORT SWETTENHAM, UPON ENTRY INTO FEDERATED MALAY STATES Estate Total Average Change in Cases with Evidence Evidence of Malaria Cases Hemoglobin of Malaria in Each Group With gain over 10% Estate No.1 .............. 13 +12.7 5 8 in 39 cases ” “ .............. 6 +11.7 +11.4 2 or 20.5% “ ” 2 .............. 20 +10.4 1 With gain of 5 to 10% Estate No. 7 ............. 24 +9.0 7 25 in 87 cases “ H 4 ............. 34 +7.8 +7 5 7 or 28.7% ” “ 8 ............. 15 +6.9 ' 6 ” ” 10 ............. 14 +5.0 5 With gain of 0 to 5% Estate NO. 5 21 +3.3 13 43 in 92 cases “ " 12 +2.8 +1 6 6 or 46.7% H “ 29 +1.2 ' ll ” ” 11 ............. 30 +0.3 13 With loss of 0 to 10% Estate No. 12 ............. 24 —2.1 16 16in 24 cases or 66.7% With loss of 10 to 20% Estate No.13 ............. 11 —11.4 9 9 in 11 cases or 81. 8% With loss over 20% Estate NO. 14 ............. 14 —21.3 14 14 in 14 cases or 100% (Fig. 66, page 74) 1791 (IHVOH HL'IVHH 'IVNOILVNHEILNI RELATIONSHIP BETWEEN SPLENIC CONDITION AND NUMBER OF HOOKWORMS HARBORED TABLE 41 EIGHTY-THREE PERSONS TREATED FOR Hooxwoxm IN KAMPONGS or JAVA Spleen Negative Spleen Palpable Spleen Enlarged Kampong No. of No. of No. of No. of No. of No. of Cases Worms Cases Worms Cases Worms Total ................. 44 1,391 10 495 29 1,683 Jaagpad ................... 0 0 1 10 14 506 Djmbatan ................. 5 332 7 337 9 371 Sawah Besar ............... 19 187 0 0 6 806 Kramat ................... 20 872 2 148 0 0 49. 5 58.0 Average number of worms. . . . 31.6 55 8 (Fig. 71, page 77) AHVWWDS HV'IOEIVL 991 TABLE 42 CORRELATION BETWEEN PRESENCE OF MALARIA AND NUMBER OF HOOKWORMS HARBORED ElGHTY-EIGHT CASES m JAVA JAIL 99I (DIVOH Hl'IVE-[H ’IVNOILVNHHINI E ‘d f A Average LAverfhgef Vl enceo verage eng 0 G’°“Ps - Cases Malaria Hemoglobin H N13“ 5 Time in Jail, 00 orm Months Group I ........................ 6 Spleen palpable; 68.2 77.3 40.0 plasmodia present A Group II ........................ 1 Spleen enlarged; 48.0 81.0 84.0 ' plasmodia present Group III ........................ l7 Spleen palpable; 63.2 106.0 25.2 plasmodia absent Group IV ........................ 3 Spleen enlarged; 41.3 200.0 25.3 plasmodia absent Group V ......................... 13 Spleen negative; 78.5 76.1 19.5 plasmodia present Group VI ........................ 48 Spleen negative; 81.2 54.8 25.9 plasmodia absent Malarious group (I—V) ............. 66.9 98.4 Non-malarious group (VI) .......... 81.2 54.8 (Fig. 72, page 78) TABLE 43 RELATIONSHIP BETWEEN NUMBER OF HOOKWORMS HARBORED AND PRESENCE OR ABSENCE OF MALARIA PLASMODIA IN BLOOD BASED ON TABLE 42, COVERING ANALYSIS OF 88 CASES 1N JAVA JAu. . . Plasmodia Plasmodia Spleen Spleen Spleen “me3.13 Plisgi‘gfa absent; present; negative; palpable; enlarged; a sen, ’ p5 eleen’ irrespec- irrespec— irrespec- irrespec- irrespec- SP een p t' tive of tive of tivc of tive of tive of negative nega we spleen spleen plasmodia plasmodia plasmodia Cases ..................... 48 13 68 20 61 23 4 Average hemoglobin .......... 81.2 78.5 74.9 73.8 80.6 64.5 43.0 Average number of worms ..... 54.8 76.1 74.0 76.7 59.2 98.5 170.5 Period of jail residence ........ 24 to 35 12 to 23 24 t035 24 to 35 24 to 35 24 to 35 35 to 47 months months months months months months months (Fig. 73, page 79) AHVWNDS HV'IOEIVJ. 291 CORRELATION BETWEEN SPLENIC CONDITION AND HOOKWORMS HARBORED TABLE 44 ONE HUNDRED SIX CASES IN JAVA JAIL NUMBER OF Spleen Negative Spleen Palpable Spleen Enlarged Cases ................................... Hemoglobin percentage ................... Hookworms (average number per case) ...... Length of time in prison (average number of months) .............................. 63 79.8 57.9 24.3 29 63.1 98.5 26.5 14 47.2 120.4 32.9 (Fig. 74, page 79) .89I GHVOEI HL’IVEIH ’IVNOILVNHELLNI TABLE 45 HEMOGLOBIN RATE AND DEGREE OF SPLENIC ENLARGEMENT IN RELATION TO LENGTH OF JAIL RESIDENCE ONE HUNDRED FIFTEEN PRISONERS 1N TREATMENT SQUADs IN JAVA JAIL Condition of Spleen Duration of Stay 1 to 3 Months 61 to 72 Months Average Average Cases Hemoglobin Cases Hemoglobin All conditions .................. 92 83.5 23 77.9 Negative ........................... 48 85.2 9 82.0 Palpable ............................ 31 83.4 6 77.8 One finger's breadth ................. S 80.6 3 73.1 Two fingers’ breadth ................. 7 76.0 2 72.5 Three fingers’ breadth ................ 1 75.0 3 74.3 (Fig. 75, page 80) AHVWWDS HV’IQHVL 691 TABLE 46 SPLENIC ENLARGEMENT IN RELATION TO LENGTH OF JAIL RESIDENCE FIVE HUNDRED NINETY-FOUR CASES IN JAVA JAIL Length of Jail Residence Cases with Enlarged Spleens (Per Cent of Total Cases Examined) Number of Cases All periods .......................... 9 days and under ........................ 1 to 3 months .......................... 4 “ 6 “ .......................... 7 “ 9 “ .......................... 10“ 12 “ .......................... 13 ” 24 ” .......................... 25 " 36 ” ........ . ................. 37 ” 48 “ .......................... 49 ” 60 “ .......................... 61“ 72 “ .......................... 73 months and over ....................... 62.5% 36.0% (Fig. 76, page 80) on GHVOH Hl’IVEIH ’IVNOILVNHEILNI TABLE 47 HOOKWORM INFECTION AND MALARIA AS ANEMIA-PRODUCING FACTORS IN DESSAS OF GEBONGELIR, JAVA BY SEX AND AGE GROUPS Men Women Boys Girls Calculated normal hemoglobin ........................ 95 86 85 85 Actual hemoglobin average of dessa group .............. 56.1 47.9 56.8 68 Calculated loss ...................................... 38.9 38.1 28.2 17 Average number of hookworms harbored ................ 80.4- 24.2 47.8 11.7 Calculated loss of hemoglobin due to hookworms‘ ....... 6.9% 2.4% 6.1% 1.5% Balances due to losses from malaria .................... 32.0 35.7 22.1 15.5 Note: In this table it is assumed that all the worms are causing a measurable amount of anemia. ‘For derivation of factors used in calculating this loss (7.8 in the case of boys and girls, and 11.7 in the case of men) see Figs. 81 and 83 and text discussion, pages 87 to 90. (Fig. 84, page 92) AHVWWOS HV'IIIHVJ. 1.41 TABLE 48 AVERAGE HEMOGLOBIN RATES AND AVERAGE NUMBER OF HOOKWORMS HARBORED IN ONE MALARIOUS AND TWO NON-MALARIOUS DESSAS or JAVA BY SEX AND AGE GROUPS Severe Malaria Free from Malaria Gebongelir Kebasekan and Kalimaro Sex and Age Groups Average Number Average Number HAverzligf} of Hookworms HAverallgg. of Hookworms emog 0 1n Harbored emogo m Harbored Men ............................... 56.1 80. 4 69. 2 303 Women ............................. 47.9 24.2 69.7 163.3 ‘ (Kebasekan only) Boys ............................... 56.8 47.8 71.5 106 Girls ............................... 68.0 11.7 83.0 63.4 Note: This table shows that not only is the more severe anemia in the malarious dessa, but that for some reason there is a decidedly smaller number of worms as well. (Fig. 85, page 93) 21.1 (DIVOH HL'IVEIH 'IVNOILVNHELLNI I! TABLE 49 RESPECTIVE LOSSES IN HEMOGLOBIN FROM HARD LABOR AND SUB-NUTRITION, MALARIA, AND HOOKWORM INFECTION PRISONERS IN BATAVlA JAIL, JAVA Number of Hookworms Harbored 0 1 to'100 101 to 200 201 to 300 301 to 400 4001V::1d Calculated normal hemoglobin ............ 95 .0 95 .0 95 .0 95 .0 95 .0 95 .0 Loss due to hard labor and sub—nutrition, i.e. difference between 85.3 and 77.3=8.0. . .. 8.0 8.0 8.0 8.0 8.0 8.0 Balance ............................... 87.0 87.0 87.0 87.0 87.0 87.0 Average hemoglobin of men with malaria and free from hookworm=76.5 ............. 76.5 76.5 76.5 76,5 76,5 76.5 Loss due to malaria ..................... 10.5 10.5 10.5 10.5 10.5 10.5 Balance after deducting losses due to hard labor and sub-nutrition, and to malaria. . 76. 5 76.5 76. 5 76. 5 76. 5 76. 5 Average hemoglobin in the worm groups... 76.5 75.3 62.7 67.4 50.0 37.5 Calculated loss due to hookworm in each group ............................... 0.0 1.2 13.8 9.1 26.5 39.0 (Fig. 86, page 94) AHVNWHS HV’IHHVL €21 ESTIMATED LOSS OF HEMOGLOBIN TABLE 50 DUE TO HOOKWORM DISEASE AMONG POPULATIONS SUBJECTED TO MALARIA, BY HOOKWORM GROUPS BASED ON 818 CASES TREATED FROM SCHOOLS, RUBBER ESTATES, PUBLIC WORKS, QUARANTINE CAMPS, AND PRISONS 1N FEDERATED MALAY STATES Number of Hookworms Harbored All Cases Irrespective of Age, Sex, Race, Total and Malaria 0 to 6 to 51 to 101 to 151 to 201 to 251 to 301 to Above 5 50 100 150 200 250 300 600 600 Number of cases .................... 818 244 351 112 44 18 15 10 17 7 Percentage distribution of cases ....... 100% 29.8 42.9 13.7 5.4 2.2 1.8 1.2 2.1 0.9 Average hemoglobin ................. 82.5 80.5 74.9 74.5 69. 8 58. 2 59.9 54.7 38.7 Average loss of hemoglobin due to worms ........................... 2.0 7.6 8.0 12.7 24.3 22.6 27.8 43.8 Total loss of hemoglobin=average loss Xnumber of cases ................ 3,503.5 702.0 851.2 352.0 228.6 364.5 226.0 472.6 306.6 (Fig. 87, page 96) ’721 GHVOH HL’IVEIH 'IVNOIlVNHEIlNI TABLE 51 LOSS OF HEMOGLOBIN FROM PROLONGED MALARIA INFECTION SUPERIMPOSED UPON HOOKWORM INFECTION HEMOGLOBIN 0F INDENTURED INDIAN COOLIES AT NAUSORI, FIJI ISLANDS, COMPARED WITH FREE JAVANESE FROM THREE KAMPONGS AND BATAVIA JAIL Number of Hookworms Harbored l to 50 51 to 100 101 to 150 Indentured Indian coolies, Nausori" Average hemoglobin .................... 85.8% 85.0% 81.8% Number of cases ....................... 31 16 9 Javanese men from three kampongs and from Batavia jailT Average hemoglobin .................... 68. 9% 68. 4% 68. 8% Number of cases ....................... 83 20 10 Diflerence=loss due partly to malaria and partly to jail regimen ................. 16.9% 16.6% 13.0% * Infected with hookworm but free of malaria. 1‘ Infected with hookworm and severely malarious. (Fig. 90, page 103) AHVWNDS HV’IOHVL 9L1 TABLE 52 CORRELATION BETWEEN NUMBER OF HOOKWORMS HARBORED AND RATE OF HEMOGLOBIN EXAMINATION OF 131 INDIANS FREE OF MALARIA BUT INFECTED WITH HooxwoxM DISEASE AT NAUSORI AND IN SUVA JAIL, FIJI ISLANDS Hemoglobin Rate Number of Total Ave. Hookworma Cases Hgb. 100 95 90 t 85 I 80 75 7O 65 60 55 50 45 40 35 30 25 20 15 10 5 0— 50 . 5 6 13 3 8 6 4 1 l 1 l 1 ........... 50 82.5 51—100.. 6 3 7 3 2 2 ................ ............ 23 85.4 101—150.. 1 1 7 3 3 ......... l ..... 1 ............ 17 79.7 151—200 . . 1 1 l 1 l 1 .................... 1. .......... 7 79.3 201—250.. 1 1 1 l l ................... 1 .................... 7 75.7 251—300.. 1 2 l l 2 ..................................................... 7 79.3 301-350.. ...... l 1 .............................. 3 65.0 351—400 . 1 ..... 1 ..... 1 .......................... 5 64.0 401—450 . .. . ..................................................... 1 35.0 451—500 . .......... l ................ 1 ,,,,, 2 50.0 501—550 . . ........................................... 1 350 551—600 . . ........................ 1 ......................... 2 550 601—650 . ....................................... 1 45.0 651—700 . . .................................. 1 1 2 15.0 701—750 . . .................................................................. —— — 751—800 . . ..................................... 1 ................ 1 40.0 801—850 . ........................................................... 1 l 5.0 1001—1050 . . .......................... 1 .............................. 1 55.0 Totalcasm 7 15 20 21 18 16 10 1 3 2 5 3 1 3 2 2 — — — 2 131 76.8 Ave Worms 75.3 72.4 69.7 11459181396 14834902497 514.5256.8418.0789.0452.7 83.05765 7585 154.5 (Figs. 91 and 92, pages 104 and 105) 911 (IHVOH HL’IVHH ’IVNOILVNHEILNI TABLE 53 TIME REQUIRED TO RAISE HEMOGLOBIN RATES OF ANEMIC PATIENTS DIFFICULTY OF RESTORING NORMAL HEMOGLOBIN VALUE IN PATIENTS AFTER TREATING THEM FOR MALARIA AND Hooxwoxm DISEASE. FIFTY-EIGHT CASES TREATED IN SPECIAL WARD AT KUALA LUMPUR HOSPITAL Average Hemoglobin on Admission 0—10 ( 11—20 I 21—30 31—40 41—50 51—60 I 61—70 71—80'81—90 Average hemoglobin on discharge ....... 38.1% 50.9% 59.5% 64.0% 61.7% 60.8% 78. 5% 82.0% 93.0% Average length of time, in days, required to raise hemoglobin ................. 81.7 63.4 48.2 57.0 53.0 35.4 52.0 22.0 21.0 Number of cases ...................... 20 9 9 6 5 5 2 1 1 Range in days ........................ 22—228 40—82 21—71 35—83 21—81 23—53 43—61 22 21 Range in increase of hemoglobin during period ............................. 5—75% 20—73% 33—75% 42—80% «18—76% 33—83% 75—82% 82% 93% (Fig. 96, page 113) AHVWWHS HV'IOHVJ. 1.2! TABLE 54 SEVERITY OF ANEMIA IN MEN, WOMEN, AND CHILDREN COMPARATIVE HEMOGLOBIN RATES or SEXES IN MALARIOUS AND NON- MALARIOUS DISTRICTS. ONE HUNDRED TEN CASES TREATED IN KAMPONGS or JAVA A. B. Cases with Hemoglobin Cases with Hemoglobin Ratio of A. to B. Particulars 60 and Over 59 and Under Men Women Children Men Women Children Men Women Children 0 Non- malarious Kam- E pongs (Kalimaro and é Kebasekan): 'E No. cases ......... 13 11 14 5 4 1 1: 0.38 1:0.36 1:11.07 '3 Average number of E hookworms har- bored .......... 208.8 95.0 91.8 608.8 201.0 163.0 1: 2.9 122.1 1:1.7 w Malarious Kampongs :1 (Gebongelir and -:2_ Endil). .2! No. cases ......... 12 5 10 8 21 6 1: 0.67 1: 4.2 1:0.6 g Average number of hookworms har- bored .......... 30.6 65.2 36.9 56.6 19.5 56 1: 1.8 1: .30 1:1.5 (Fig. 97, page 116) 811 (IHVOH HL’IVEIH ’IVNOILVNXCELLNI INDEX PAGE ACACIA. 27 AGAR, SOLUTION or NUTRIENT: Incentrifugemethod” . 25 ALBUMINURIA .............................................. 39-40 ANCYLOSTOMA CEYLANICUM. . . . . . . .....55,56,60 ANCYLOSTOMA DUODENALE: Importance of distribution and relative numbers .............. 55 Comparative malignancy... . .,106 109,110 Also .55, 56, 57, 58, 59, 60, 63 99, 102 ANCYLOSTOME FORMULA 55 ANCYLOSTOME INDEX: Cluetoethnicorigin....................................... 64 ANCYLOSTOMES. Experiments on relative resistance of sexes to vermicides ...... 47—49 Mouthparts.. . 52 Conditions limiting proportions. .. . . . . .. . . .. . . . . .. .. .. ... 55 Percentage among adult Malays... 56 Percentage among Chinese at District Hospital, Kuala Lumpur 56 Percentage among Tamils... . . . . .. . 57 Percentage among night-soil coolies at Kuala Lumpur.. . . . . . 57 Percentage among road coolies. . . . .. .. . . .. .. . . . . .. 58 Percentage amongSikhs............... 58— 59 AmongJapanese.......................................... 59 Percentagein Java 60 Also... ...................20,33,34,35,41,56 See also Names of species ANEMIA: Correlated with worms and splenic enlargement .............. 80, 92 Result of malaria and hookworm disease .............. 90—91, 92, 93 Othercausalfactors. 93 Amountduetomalaria. 94 Quantitative value of hookworms as cause .................... 95 Relation to hookworm disease 1n Fiji... .. . . . . .. .. . 101 Investigations on varying degrees caused by hookworms,102- 104, 106 Experiments on comparative malignancy of hookworms, 106,109,110 AmongChineseandTamilcoolies.. 112 Severityinwomen” . ........................115,116 AmongChmesecoohes1nt1nm1nes 117 Also .................................................. 12 See also Hemoglobin ANOPHELES KAWARI 68 179 I80 INDEX PAGE ANOPHELESKOO-11.......................................... 68 ANOPHELESLUDLOWI.......................................63,69 ANOPHELESMAcULATus...................................., 6‘) ANOPHELESROSSI........................................... 68 ANOPHELES TESSELLATUS .................................... 68 ANOPHELESUMBROSUS....................................... 68 ANOPHELINES: SpeciesoccurringatPortSwettenham...............,...._... 68 ASCARIS 33 AscersllO BALI EAST INDIES.........................................63,64 BARBADOS . 8,81 BARBER, DR. MARSHALL A. Nlember Uncinariasis Commission to the Orient ............... 15 BATAVIA: Percentage of ancylostomes at jail” . . . . . . . .. . 60 Incidence of hookworm infection and malaria 1n jail .......... 77— 78 Correlation between presence of malaria and number of worms amongprisoners. . 78 Average hemoglobinof boysmkampong 88 Causesofanemia amongprisoners. 93 Also .10210+ BATAVIA GEFANGENIS ....................................... 104 BATAVIA JAIL, see BATAVIA BATAVXA STADSVERBAND........ 101 BEADS, GLASS: For identification of specimens in fecal examinations. . . .. . . . .. . 28 BENGALESE . 21 BERIBERICS.........,..................,...... .88—89101,10-1 BETA-NAPTHHOL............................................. 34 BLOOD, EXAMINATION 01‘: At District Hospital, Kuala Lumpur” .. .. .. .. .. .. . . . . . . . .65—66 Parasitic rates at Port Swettenham. .. .. 67 Résumé of findings by the Commission 1n the Federated ”Nialay States” .67-68 In a case of malaria mistaken for hookworm disease. . .. .. .. . . 110 See also Erythrocytes; Hemoglobin BLOOD REGENERATION: Investigations on effect of hookworm infection. . . . . .. . . . .. .111-114 Inuncomplicatedhookworminfection.....................114>—115 In uncomplicated malariainfection......,.... .. 115 INDEX 181 PAGE BOYS: Percentage of hookworms at Kampong Bharu and UluGombak, 55—56 Investigations on standard normal content of hemoglobin, 87—88, 89-90 Calculated normalhemoglobin at Gebongelir“ .. 95 Number of worms required to cause loss of l per cent of hemo- globin. 93 See also Schools CACHEXIA 65 CALO‘VIEL 42 CASTOROIL......................................27,34,39—40,42 CELEBES,EASTINDIEs...................................... 63 CENTRIFUGE MEFHODZ Details Of procedure and comparison of methods ............. 25—27 See also Smear method CEYLON. .. . 12 CHENOPODIUM, see OIL OF CHENOPODIUM CHILDREN: Thymolintreatment. . 35 Examined for hookworm 1nfect1on .. 4..7, 69 Percenta 7e of hookworm infection at Singapore .............. 52-53 Spleenrate. . 67 Average hemoglobin content Injava ......,......84,87 Ratiooflossofhemoglobin to number ofworms.. .. 100 Hemoglobin rates in Fiji ................................... 100 Also. 102 See also Boys; Girls; Schools CHINESE COOLIEs: Personalcharacteristics............. 3—4 Comparedwith Tamils. . 4 112— 113 Valueaslaborers . Examination and treatment. . . . . .16, 21 Mortality from hookworm disease and malaria In District Hospi- talflKualaLumpur .....51- 52 Worm-species formula... . . . . . 56 Percentage of hookworms among sinkehs In Singapore” 5H6, 59, 84 Necator americanus among Straits- born Chinese ............... 57 Ratio of loss of hemoglobin to number of worms ............... 99 Investigations on rate of blood regeneration ............... 111—114 Also. . 34 CHLOROFORM 34 COLONIAL JAIL, SUVA, see PRISONERS CONVEN’I‘ SCHOOL, KUALA LUMPUR, see SCHOOLS COOLIEs, see CHINESE COOLIEs; INDENTURED COOLIEs; INDIAN COOLIEs; NIGHT-SOIL COOLIEs; ROAD COOLIEs; TAMIL COOLIEs I 82 INDEX PAGE DARE’s INSTRUMENT......................................... 84 DARLING, DR. SAMUEL T. Appointed Chairman of Uncinariasis Commission to the Orient. . 15 DEMENTIAPRAECOX. . 41 DETENTION CAMPS, see PORT SwETTENIiAM; SINGAPORE DIARRHEA. 110 DISTRIC’I HOSPITAL, KUALA LUMPUR, FEDERATED MALAY STATES: Permanent headquarters of Uncinariasis Commission to the Orient... 16 Examinations for plasmodia and hOOkworiri ova ............... 21 Experiments In administration of vermicides .................. 33 Comparative fatality of malaria and hookworm disease .. . . . . .. . 51 Incidence of fatal disease shown by post—mortems ............. 51 Percentageofhookworms amongChinese..................... 56 Fatalitiesfrommalaria..................... 65 Also. ..5,16,42,104,111 See also Kampong Bharu DYSENTERY................................................21,51 EASTJAVA.........I.....I......I...I..I...............60,63,64 EDEMA110,111 EGYPT 12 ENDIL,JAVA..I.I..........................................64,74 ERYTHROCYTES: Lossaftertreatmentbychenopodium................... .3849 Also. . ...........111, 114,115 See also Blood Regeneration; Hemoglobin ESTATES: Re-examination of coolies for hookworm infection ............ 19—20 Malariasurvey..........................,..........69—-70,73-74 EUCALYPTUS 34 EURASIANS 21 EUROPEANS................................................21,59 FECES, EXAMINATION or: Identificationofspecimens.......,.........................27—28 Washingofstools.....”.............................I......28.31 Collectionofstools. 32-33 AtPortSwettenham 47 At District Hospital, Kuala Lumpur 66 See also Centrifuge Method; Smear Method INDEX 183 PAGE FEDERATED MALAY STATES: Organized public health work. , . . 5,7 Examination of children, miners, hospital patients, prisoners and coolies ................................................. 20 Relative seriousness of malaria. . . . . . . . .. .. . . . . . 90 Analysis of cases treated for hookworm disease , . . . . . . . , .95—96 Also... 12,81 See also Names of places F111 ISLANDS. Climate... 8 Character1st1csofnatnes 8 Indiancoolies. .. . 8,11 Prevalence of hookworm infection. ... .. . .. .... . , ,. .. ...53, 101 Malarianotendemic.................. .. 82 Examinationsforanemia......,......,,,. .100—101 See also Names of places F111 MEDICAL DEPARTMENT.................................. 53 FILAmA 82 GEBONGELIR, JAVA................ .....60,74,93,95 GIRLS: Calculated normal hemoglobin at Gebongelir .. .. .. .. . .. .. .. .. . 95 Also. . 20,95 See also Schools GLAss BEADS: For identification of specimens in fecal examinations ........... 28 GLYCERINE................................................22,25 HACKER, DR. H. P. Member Uncinariasis Commission to the Orient ............... 15 HAST1Nc’s STAIN....... ,. .. 82 HEMATOPOIESIS.............................................114 HEMOGLOEIN: ‘After—efi'ects of treatment b\ \ ermicidal drugs ............... 38— 39 Percentage at Singapore. . . .52— 53 Gains and losses affected bv malaria and hookworm disease 70, 73— 74 Average for malarial and non- -malarial groups in Java jail ...... 78 Influences of sex and age on values. . .. .. .. .. .. .. .. .. .83—84 Averages given by Dare’ 5 instrument. . . . . . .. . . .. .. . . . . . 84 Measures to determine normal average con.tent . . . . 84 Effect of pregnancy. . . 8.4, 89, 101, 116 Control determinations of members of the Commission ......... 87 Investigations on standard normal content in a mixed population, 87— 88 Rates among beriberics and prisoner clerks in Batavia, 88—89, 101—102 Numbers of worms required to cause loss of 1 per cent . .89, 91, 92-93 Losses due to hookworm disease. .. .. .. .. .. .. .. .92,99 Influence of diet and hard labor. . . .. .. .. .. .. .. .. ...93—94,104 I 84 INDEX PAGE HEMOGLOBIN—canlinued Estimate of loss due to malaria .............................. 94 Comparison in sex and age groups ........................... 95 Losses compared by various worm groups ............ 95—96, 99-100 Representative male standard ............................... 102 Average rates among indentured coolies and prisoners ....... 102—104- Fijiantreatmentsquad..106 In a malaria- free group. .. . . . . . . . .. 106 In a case of malaria mistaken lor hooknorm disease ........ 111— 112 Difficulty of raising value ................................... 113 See also Blood Regeneration Hooxwom DISEASE: PrevalenceintheOrient. 12 In relation to malaria... . . . . . . 15 70, 7-1 77—79 Treatment of coolies at detention camps. . . . . . . 16 Results of re- examination on estates. . .. . . .. .. .. .. .. . . .. .19-20 Infection among children. . . . . . .. . . . . . 47 Post- mortems at District Hospital, Kuala Lumpur . . .. . . .. .51—52 Comparative severity between Chinese and Tamil coolies. .. . . .51—52 Percentage of infection at Singapore. . . . . .. .... . . .. .. .. .. ...52—53 Prevalence 1n the Fiji Islands... . .53, 55 Sources of infection among Europeans and Chinese 1n Federated MalayStates” 59 Examinations at District Hospital Kuala Lumpur . . . .. . . . 66 Among children with low hemoglobin average... . . . . . . . .. . 69 Correlation between presence of malaria and number of 11 orms 78 Splenic enlargement and high worm counts .................. 80— 81 Lowest incidence of infection .............................. 84, 87 Relative seriousness in Federated Malay States and Jan a ....... 90 Cause of lowered hemoglobin values... , . . . . . . . . .92 93 Effect on hemoglobin among prisoners in Jax a ................ 94 Factor 1n producing malaria at Gebongelin. . . . . . 95 Analysis of cases treated 1n Federated Malay States . ..95—96 99— 100 RelationtoanemiainFijL. .—101105 Eflect on blood regeneration. . 111— 114 Also. .. .. .21, 70, 73, 7-1 77, 82, 83, 109— 110 See also Vermicidal Treatment l'or Hook“ orm Disease Hooxwom OVA, DETECTION or, see Faces, Examxnrlox or Hooxwoms: Percentage of removals. . . . . .. .. . . . . .50—51 Percentage among boys at Ulu Gombak ...................... 55 Differentiation and distribution of species ................... 55— 57 Percentage among adult Malays. . .. . . . .. .. . 56 Number required to produce a loss of 1 per cent hemoglobin 89, 91, 92—93 Experiments on comparative malignancy. . . . .. . . . . . . . .106, 109—1 10 See also Names of species INDEX 185 PAGE INDENTURED COOLIES: Standardsofhemoglobin................................102-103 INDIANCOOLIESH ..........................8,ll,101 INTERNATIONAL HEALTH BOARD: In co-operationwiththeFiiiMedicalDepartment............. 53 AlsolZ,15 JAAGPAD, JAVA .. . . . 7-1 JAILS see BATAVIA; PRISONERS; SUVA, FIJI ISLANDS; TAIPING JAIL, FEDERATED MALAY STATES JAPANESE: Percentage of ancylostomes among prostitutes ................ 59 Also 21 JAVA: Nativepopulation.. .. 7 Hookworm infection and malaria ............................ 21 Correspondence between malaria and hookworm infection in kampongs” .. . .. ..74, 77 Investigations on standard normal content of hemoglobin ....... 87-88 Relative seriousness of hookworm disease. . . . . . . .. . . . .. .. . 90 Findings on hemoglobin values .............................. 92 Also. . .........................2,81,99,104 See also Names mof places JAVA JAIL, see BATAVIA JOHORE,FEDERATEDMALAY STATES......................... S KAJANG, FEDERATED MALAY STATES .......................... 110 KALIMARO,JAVA.. ”6077,87 88, 89,9,092 95 KAMPONG BHARU, FEDERATED MALAY STATES ................ 20,55 KEBASEKAN,JAVA...........................60,77,88,89,90,92,9S KIDNEYS, see URINE KRAKAL,JAVA.............................................. 77 KRAKAL-KARANGSARI, JAVA 60 KRAMAT,JAVA.. . .89, 90, 92 KUALA LUMPUR, see District Hospital, Kuala Iumpur, Federated Malay States LOMBAK, EAST INDIES ....................................... 63 MADRAs PRESIDENCY........................................ MADURA, EAST INDIES 63 MAGNESIUM SULPHATE...................................27,32,42 MALACCA ................................................... 57 MALAEARIS....................,..........................57,lll 1 86 INDEX PAGE MALARIA: Not co—extensive with hookworm disease ..................... 8 Surveys in vicinity of Kuala Lumpur ........................ 16 Fatalities at District Hospital, Kuala Lumpur ................ 51 Post-mortems at District Hospital, Kuala Lumpur“ . . . . . . . . 65 Survey at Port Swettcnham ............................... 68—69 Surveys on estates .................................. 69—70, 73—74 Relation to hookworm disease on kampongs in Java ....... 74, 77—78 Among prisoners in Java... . . . . . . . 80 Results of control investigations at Viti Levu . . , . . . . .. .81—82 Lowest incidence of infection .............................. 8-1—87 Relative seriousness in Federated Malay States and Java ....... 90 Effect on hemoglobin ...................................... 99 Mistaken for hookworm disease ............................. 110 Effect of hookworm infection on blood regeneration ......... 111— 114 Also. . . 12, 15 See also Blood Examination of; Blood Regeneration MALAY PENINSULA: Topography and climate. . 1 Population... . . . 2—3 Schools. .. . 4 Principal industries. . 4—5 Under British protection. . . . . 1 . . . 5 See also Federated Malay States; Singapore MALAYs: Percentageofhookworms. .. .. ...55—56 Also . . . . .21, 34 MAL-NUTRITioN, see SUB~NUTRITioN MEN: Average normal hemoglobin... . . . . . .88—90 Number of worms required to cause loss of 1 per cent of heino- globin.. . 93 Calculated normal hemoglobin at Gebongelir . . . . . . 95 Ratio of loss of hemoglobin to number of worms. . . 99,100 Hemoglobin rates in Fiji ................................... 100 MICROSCOPIC SLIDEs......,..i.................,.......,i...22,25 MID-JAVA.. . .. . . . . . .(10, 63,64 MOHAMMEDAN POLICE, sre Sums MOHAMMEDANS..........................,.,................ 2 MURUGAN, A TAMIL DHOBY............,........,....,....110-111 NaCl, SATURATED SOLUTION 012............................22,25 NASAQO, FIJI ISLANDS................................. 82 NAUSORI, FIJI ISLANDS.......................fl... NAUSORI INDIANS .81,82,101,102 106 INDEX 1 87 PAGE NECATOR AMERICANUS: Experiments on relative resistance of sexes to vermicides. . . ..47—49 Mouthparts.. 52 Natural paras1teofF111ans 55 Conditionslimitingproportions. .. .. 55 AmongStraits-bornChinese” ........ 57 Comparative malignancy” .106,109,110 Also. . .20 33, W34 35, 41 55, 56, 57, 58, S9, 60, 63, 99, 102 NEGRI SEMBILAN, FEDERATED MALAY STATES ................. 5 NIGHT-SOIL CoouEs: Examinations for comparative Study ......................... 20 Percentageofancylostomes...... .. 58 NON-FEDERATED MALAY STATES........... 5 NORTH INDIANS, see SIKHS OIL OF CHENOPODIUMZ Methodofadministering.............................. 27 Comparisonwiththymol........................ ..33— 34, 35 Formanddosage” . “34,316 Price per mi] and relative cost of treatment. .. . . . . .. .. . . .36—37 Toxicefi'ectsupon thekidneys” 39—41 Symptomsofdementiapraecox.m............................ 41 Causes vomiting... ..41—42 Percentage of worms removed by first and second treatments . 50 Also... . . . .16,78110,114 OVA, DETECTION OF, see FEcEs, EXAMINATION 0F PAHANG, FEDERATED MALAY STATES 5 PANGHOR TREATY .......................................... 5 PENANG, STRAITS SETTLEMENTS 12 PERAK, FEDERATED MALAY STATES 5 PHILIPPINE ISLANDS. 12 PLASMODIA: Positive and negative evidence of malaria ................... 77—78 Analysis of cases with regard to relation of worms ............ 78— 79 Amongprisoners.............................. 80 Also. .21, 65, 111— 112 See also Blood, Examination of; Malaria POLYNESIANS. .. 82 PORT SWE'I'I‘ENIiAM, FEDERATED MALAY STATES: Quarantine camp and examination of Tamil coolies ........... 16,19 Examinations for hookworm infection .................... 25—26, 47 Results of treatment for hookworm infection .................. 57 Spleen examinations among coolies .......................... 66 I 88 INDEX PAGE PORT SWETTENHAM—fimnflnued ' Results of blood examinations ............................... 67 Malaria survey . ..... . . . . . . .-68 69 Results of examinations for heniOglobin rates ............. 70, 73—74 Alma. .. ...................................8, 52, 84, 95 POSFNJORTEM EXAhHNATIONS. .........u..........”.....51,65 PREANGER, JAVA 60 PREGNANCY,see\VOMEN PRmONERs: Comparison with mine workers... .. . 1 .. .. .. .1 .. ..... 21 Percentage of ancylostomes at jail In Sumatra ................. 63 Malaria survey at Colonial jail, Suva. .... .. ... ..... .. ... 81 Deficientinhemoglobin” . .............102 See also Batavia; Taipimng Jail PROSTITUTES..... .......................................... 59 PURGEE Cknnparafive values....................................... 42 See also Names of drugs QUARANTINE CAMPS, see Pox-r SWET’I‘ENHAM; SINGAPORE QLnNINE.. .....,....................................110,ll4,115 REWA RIVER, FIJI ISLANDS.................................81,82 ROAD COOLIES: Percentage of ancylostornes.. ........ ............ .......... . 58 ST. JOHN’S ISLAND, see SINGAPORE SAWAH BESAR,JAVA........n.....u....u......”......”. 92 SCHOOLS. Treatment at Kampong Bl1aru . . . . .. . . . . . . ... 20 Treatment at Convent school at Kuala Lumpur. . .. . . .. .. . 20 Examination of students at Victoria school ................... 21 Hemoglobin rates atVictoria school. .. .. . . .. .. 101 Also 82 See also Boys; Children; Girls SELANGOR, FEDERATED hAALAY STATES........................ 5 SENNA.....u....H...H....”....H....H....H....H..... 42 SIKHs: Percentage of ancylostomes in the Federated Malay States ..... 58—59 Abe ................................................... L21 SINGALESE 21 INDEX 189 PAGE SINGAPORE, STRAITS SETTLEMENTS: Percentage of hookworms among sinkehs at St. John’s Island. .. . 56 Results of examinations at St. John’s Island. . . . . .. .. .. .. .52—53,84 Also...............................................12,16,95 SINKEH556,S9,84 SLIDES, NIICROSCOPIC...........................1...........22,25 SMEAR METHOD: Detailsofprocedure. .22 25 Comparison of methods. .25 27 See also Centrifuge \1ethod;Vermicidal '1 reatment fOr HOok- worm Disease SODIUMSULPHATE.. ..... 27 SOUTH INDIANS, see \1alabaris;Telegus SPLEEN: Examination and classification ............................. 66—67 Rateamongchildren......-................................. 67 RatesinJavakampongs” 74 Asevidenceofmalaria. ......77-78 Enlargementamongpnsoncrs1nJava ..................80—81 Resultsofcontrolinvestigationsat Fiji.. 82 Also ................................................... 79 See also Blood, Examination of; Plasmodia SPOROZOITES................................................ 68 STOOLS, see FECES, EXAMINATION OF STRAITS-BORN CHINESE 57 STRAITS SETTLEMENTS 2 Seealsa Singapore SUB-NUTRITION: Causcofanemia........................................... 93 Nativepopulation......................................... 7 SUMATRA: Investigation of methods of treating hookworm disease .. .. . . .. . 21 Percentage of ancylostomes ................................. 63 A15064,81 SUVA, FIJI ISLANDS: Low hemoglobin among Indians in jail. . . .. .. .. 102 Also 81,82,104,106 TAIPING JAIL, FEDERATED MALAY STATES: Clinicalexaminations. 21 Routine technique of treatment . .. . . .. .. ., .. .. .. .. .. .. .32—33 Experiments with vermicides ................................ 34 Also41—42 I 90 INDEX PAGE TAMIL CoouEs: Originandcharaeteristics.. 3 Compared with Chinese ............................... 4 112— 113 Examination and treatment. . . . . . . . . . . . . .,16 21 Details of examination at Port Swettenhahi” . . . .. .. .. .. .. . 19 Re—examination on estates. . . . . . .19 20 Mortality from hookworm disease and malaria In District Hos- pitalflKualaLumpur 5.1—52 Percentage of ancylostomes ................................. 57 Infection from Chinese sources ............................. 57—58 Hemoglobin determinations. . . ............... 84 Ratio of loss of hemoglobin to number of worms ............... 99 Investigations on rate of blood regeneration... . . . .1—11 114 Religious and caste restrictions .............................. 112 Also ................................................... 34 TELEGUS. . 57‘ TEST TUBE, see CENTRIEUGE lVIETIIOD THYMOL: Comparison with oil of chenopodium . . . .. .. .. ........ .33—34, 35,42 Formanddosage” .. ................27,34 Price per grain and relative cost of treatment . . .. . . .. . . . .36—37 Toxicsymptomsu 41 Also... 16 TIMOR, EAST INbIEs. 63 TIN MINES: Results of examinations for hookworm disease and comparison with prisoners at Taiping jail. . . . . . .. . . .. . . . . . .... 20—21 Also... . . 5 TREATMENT FOR HOOKWORM DisEAsE, see V ERMICIDAI. TREATMENT FOR HOOKWORM DISEASE TRICHURIS 33 TUBERCULOSIS.............................................. 51 ULU GOMEAK, FEDERATED MALAY STATES: Treatment of boys for hookworm disease. . . . .. . . . . I. .. .. ....55—56 UNCINARIAsIs COMMISSION To THE ORIENT: Field of Operations. . . 2 Preliminary tour by the Gehei'al DirectOr of the Ihterriatiohal HealthBoard. 12 Attitude of British Government ............................. 12 Appointed by the International Health Board. . .. 1. . . . . . .. ...12, 15 Personnelandpurpose.. .. 15 HeadquartersatKualaLuiripur 16 Methods of Inquiry ........................................ 16 Resultsofinvestigations........,........................... 21 INDEX 191 . PAGE UNCINARIASIS COMMISSION To THE ORIENT—continued Control determinations of hemoglobin of members ............. 87 Decision regarding malaria ................................. 90 URINE: Testson presenceofchenopodium. . . .39,4l VANIMORA, FIJIISLANDS.. . 82 VERMICIDAL TREATMENT FOR HooKwoRM DISEASE. Detailsofproceduren 27 Routinetechnique” . ..32—33 Series conducted at Kuala Lumpur ....................... 33-34 Experiments at Taiping jail. . . . .-. .34—35 Series to determine action and results of different doses of chen— Opodium.. 36 Relative costs ............................................ 36-37 After-eflects. 37-39 Diet. . 42 ( omparative effects of higher and lower doses. . . . .. . . .. . . . 49 Comparative results of first and second treatments ........... 50-51 See also Names Of Drugs VICTORIA SCHOOL, see SCHOOLS VITI LEvu, FIJI ISLANDS: Field for intensive study of hookworm discase.. . . . . . . . . . . .. . . . 8 Control investigations on hookworm disease .................. 21 Percentageofhookworminfection...... 53 Control investigations on malaria.. . . .. .1...... .. . . .. .... .. .81—82 Hemoglobinrates.................'......................... 100 VOMITING': Caused by chenopodium and thymol. .. .... 1. ........ .37—38,41—42 WEST JAVA ................................................ 60, 63 WOMEN: Effect of pregnancy on hemoglobin. . . . . . .. . . 1. .. .. .84, 89,101,116 Average hemoglobin ...................................... 89—90 Calculated normal hemoglobin at Gebongelir .................. 95 Rate of loss of hemoglobin to number of worms ............... lOO HemoglobinratesinFiji“ 100 Severity of anemia during. pregnancy ...................... 115— 116 Also... 102 WORM—SPECIES FORMULA. OftheChinese. 56 For Straits- born Chinese and South Indians . . . . . . . .. .. .. .. . .57-58 AmongSumatrans......................................... 63 WORMS, see HOOKWORMS EEEEEEEEEEEEEEEEE