FILARIA DRACUNCULUS OR MEDINENSIS AT KHERWARRAH.

By Assistant Surgeon T. H. IIendley, Meywar Bheel Corps. Access to records ranging over twenty-seven years, and

including particulars of some 3,200 cases, might be expected to throw some light upon the etiology and treatment of guinea worm; but so many difficulties enter into .the investigation of questions of the kind, that little additional information to that

already known has been elicited; nevertheless, a few points of interest come out from the examination of the records referred to.

The cases were all admitted into the hospital of the Meywar Bheel Corps from amongst the men serving in the regiment, and the great majority at Kherwarrah, although a very strong detachment is permanently stationed at Kotrah: it may not be

uninteresting, therefore, to begin with a short description of both stations, at the same time referring to the conditions under which the men serve.

Kherwarrah is situated in a valley in the midst of the hilly tract of Meywar; the station rests upon a basis of trap, a small nullah skirts it on the west and north, which is only running for a few weeks in the i-ains ; during the remainder of the year it is represented by a chain of dirty pools ; the soil is richly alluvial, very shallow, moist and constantly enriched by the addition of matter from the disintegrating rocks beneath.

Ivotrah is situated in a more open valley, but a much larger river runs past the station. The custom exists of allowing the Bheels, who form the bulk of the regiment, and are the great sufferers from dracunculus, to visit their pals (villages) in the neighbourhood of their stations for at least two months in the

summer season, to enable them to cultivate their fields. This

practice exists to a less extent at Kotrah, as from the greater size of the valley, the men are enabled to obtain khets near the station: hence they are not so far removed from an abundant

supply of water. The country is everywhere hilly, the soil

shallow, the reeky basis disintegrating trap. "Water is scarce, but the soil moist; almost every village has its pool in which the inhabitants bathe, and in every case this pool contains

extremely dirty water: it is from washing in this water, I

believe, that the disease arises, and not from drinking it, as

some of my predecessors have imagined, chiefly on the ground that the people of the bazar and the Mussalmans rarely suffer; but there are so many weighty arguments in favour of the entry of the worm into the system through the cuticle direct, that I think this may be considered an erroneous view.

The filariae may be given to animals to drink in any num-

ber, and yet the worm will not be developed. Bheesties often,

suffer from the disease, but it is said that the chief seat of affec- tion in them is the back; if this be true it is an argument against the opinion that in the majority of cases the worm is found in the lower extremities, simply from the force of gravity :

it would seem more natural to suppose that the parasite rests

and grows at the place of entry. Moreover direct proof has been obtained that the worm enters into the system when, or the entry dates from, bathing in tanks of evil repute. "Wit- ness* the case where 21 out of 50 bathers at Bombay were affected, and the more instructive case still of H. M.'s

18th Regiment at Trimulgherry, which alone suffered out of a .considerable force in the station, and which alone bathed in the water of a suspected tank. The freedom of the bazar people

* Carter.

is more easily explained from the fact that they never leave the station, where more water for washing can be obtained than is found near the and that their houses are built upon the

rock itself without the intervention of soil; however, it is fair to add that the people themselves are of the opinion that it

enters through the drinking water. I think it is now generally admitted that in every case there is a period of incubation of at least a year. Correlating temperature, rain-fall, and number of cases, I find that the following may be almost looked upon as a certain rule; namely, when in a certain year there is a small rain-fall followed in the cold season and spring of the next year by great heat, in the third summer a decrease in the number of admissions will take place : the converse holds good. This points to a moist soil as more conducive to the spread of the disease than a dry one. 3,229 cases were admitted in the 27 years ending with December 1870, giving a yearly average of 1195, or at the rate of 130 31 per thousand of strength. 2,653 cases,

or more than ̂ fths of the whole, were admitted in the six summer months from March to August, rather less than -&ths in Septem- ber and October, and hardly -fgth in the four cold months. In

December and January the admissions are always few in number ; in February there is still a slight increase, but in March the admissions are at once quadrupled, and in May and June a maxi- mum is reached. The average rain-fall in Kherwarrah is 26"39 inches per annum, and I believe the smallness of the fall to be an essential point, as there is enough to saturate the soil, but not enough to swamp it, or to prevent the pools from becoming shallow in the summer. The reason of the diminution of the cases after drought I believe to be, that the soil is too rapidly dried after a small rain-fall, thus preventing the due develope- ment of the parent worm. Dracunculus is prevalent in Upper' Egypt, where the conditions are very similar:?the Nile rises

rapidly, covers the earth with an alluvial deposit, then as rapid- ly sinks; here, too, there exists a moist, rich soil, but not

enough of rain-fall or water power to conceal, wash away or des-

troy the worm. The months of May and June are the hottest in Kherwarrah, the average temperature being 93-05? F. and 89 97? F. respectively, whilst the rain-fall in May is almost nil, and in June only 4 99 inches, most of which falls towards the close of the month. The men also for the most part are at their

homes, where they become infected with the disease. I think

I may venture to put forth the following points as in the main true, or at least worthy of attention :?

1. That guinea worm never appears until the sufferer has been at least twelve months the habitat of the worm.

2. That entrance is obtained through the cuticle probably by way of a sweat duct, whilst bathing, and perhaps, in rare instances, by drinking water, as in those cases where the intes- tines have been perforated and peritonitis set up.

3. That the date of exit is determined by the maturity of the worm, coupled with the accident of position in the cellular tissue; the latter would also determine the size.

4. That as by far the great majority of the worms occur in the lower extremities. This is a strong argument, that the entry is obtained when the patient is passing through pools either in

bathing or going to or coming from his home. The fact that

natives are much more liable than Europeans, probably from their habit of going about with naked feet (their drinking water is the same, although Europeans may occasionally filter

it) ought to exclude the theory of admission by the stomach. 4. That no external circumstances such as presence or ab-

sence of cloud, increased temperature, &c., would or could induce the worm to find its way to the surface.

6. That dracunculus can only exist or the parent worm arrive at maturity in districts between the isotherms of 77-5?

north and south, at the least, that the rain-fall must be small, but sufficient to thoroughly saturate the soil; or instead, that the

supply of water must not be constant, but only sufficient to fur- nish a thoroughly moist earth.

60 TIIE INDIAN MEDICAL GAZETTE. [Maech 1, 1S72.

7. That the soil ought to be shallow, or the water at least prevented from running off by a non-absorbing layer of rock beneath.

8. That the soil should be a rich alluvium, and if fed by disintegration of the primitive or metamorpnie rocks, so much the more favourable to development.

9. That the nearer the sub-soil water is to the surface, the more likely is the worm to arrive at maturity, but this conclu-

sion is more liable to error than the others: ?at Kotrah the

water is low and appears to be sinking. The town of Lagos, on the west coast of Africa, has al-

ways been celebrated for the prevalence of guinea worm ; the

conditions are not unlike those of Kherwarrah. Rich alluvial

deposits in many places exist, some twelve feet deep ; they are always moist and but little more than this ; moreover the natives

are very filthy in their habits. In Barbado.es in former years many admissions from this disease took place, but since the im- provements in drainage, an alteration for the better has occur-

red.

Treatment.?It is exceedingly rare ever to hear of a death from the disease in this part of llajpootana. I have, not been

able to find one case in my returns; still it is my impression that many men are permanently injured, and as on the aver- age every man remains from 20 to 30 days on the sick list, there is a great loss of service to Government. I should say from 5 to 7 men are permanently hors-de-combat ; as a rule there is no difficulty in the treatment, the men generally apply for admission alter the worm has begun to snow itself; all that can be done is to confine the man to his bed, and secure the end of the parasite by rolling it round a small piece of stick- ing plaster, and winding a little more upon it every day ; gentle traction may be used, but great care should be taken not to break the worm, as in that case absuesses and other disagreeable spqueloe may occur. Abscesses must be opened, but amongst the Bheels with some caution, as they greatly fear the use of the knife. Tonics are often essential to recovery. Cold water

poured from above and poultices also seem to aid in the extru- sion of the worm. The expelled portions ought to be.destroy- ed. I believe the greatest sufferers, and those in whom more than one worm is found, are generally the weakest in health, and least strong in the regiment.

List of places in which Dracunculits is prevalent, also showing the circumstances which seem to favour its spread.

Place. Temperature.

pherwarrah ...

Sirdarpore

Deolee

F. 78-80?. Small ampli- tude of yearly fluctuation.

Kain-fall, &c. Geology, soil,&c. Position

2G-39 inches. Irrigation in

use; sand al-

ways moist.

33'62 inches in 18(59 ; about the average.

Water scarce; 40'1 inches in 1869 ; consi- dered unusu-

ally heavy; tanks foul.

Ilapidly disinte- N. Lat. 21? grating trap shallow soil; rock almost

every where, cropping up above the sur- face.

li.Long. 74.? 1,200 feet above sea.

Soil shallow, j 1,900 feet placed over

Bolia trap which crops up abuudant-

ty; A bed of kun- kur, underlies the soil at a

depth of from 16 to 18 inches; n uneroui

rocky hillg in the district, which is dry; primitive rocks. (Dr. Kendall).

above sea.

K. Lat. 25?

K.Longi 75?

Qoonah IJed laterite, with occasion- al patches of black decom-

posed trap.

Place.

Kohat

Buunoo

Dera Ismael and Dera Ghazee Khan.

South India

Persia, South.

Shores of Cas- pian.

Shores of lied Sea.

Upper Egypt.

Temperature.

The land, near the Nile sources rests

mainly upon primitive rocks.

Gold Coast 78? (Adams) due to con-

stantpresence of cloud.

Barbadoes ... 80'1? P.

Bain-fall, &c. |Geology,soil, &c.

Irrigation ex-

cessive ; wa-

ter very bad.

Irrigation ex-

cessive ; drain- age bad.

On the Indus, which inun- dates the land,

Excessive irri-

gation, but little raiu.

Heat excessive, enough to

neutralize the

great rain-fall.

A heap of stones only partially co- vered with soil.

Soil alluvial.

Metamorpliic rocks.

Primitive rocks; also volcanic-; limes to ne, clay and allu- vium ; soil shallow.

Alluvium.

Nile rises in J uly, land dry in November; rich alluvium left behind; the Alhara branch of the river

brings down a great quantity of rich mat-

ter ; 25 left rise at Cairo, 40 atKartoum, ?1 to 5 in tho

Delta; depth of alluvium 4 to 6 inches.

40 inches of rain.

K a i n-f a 1 1 40 inches.

Granitic and

crystal lime rocks extend all along the shore.

Upper Egypt.? disintegrating liaiesto ne.

Abyssinia,? Sandstone.

Nubia,?Granite and sandstone

Metamorphic rocks, rich alluvium.

Temperature everywhere equable. Bain-fall small, or if great, accompanied by increased temperature, isoil shallow, aud rocks disintegrating. If no rain-

fall, its place is taken by inundation.

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