318 THE INDIAN MEDICAL GAZETTE [June, 1934

THE INCIDENCE OF CLONORCHIS survey of the subject that there are no endemic INFECTION IN INDIA* cases of clonorchis or opisthorchis infection anywhere in India or Burma, although they K. N. b.sc. d.t.m. (Cal. and By BAGCHI, m.u., (Cal.), are very common in China and Indo-China. Liv.), f.i.c. (Lond.) Manson-Bahr, on the other hand, while dealing Public Health Laboratories, Patna with the subject of clonorchiasis in his book, ' the The literature on the incidence of flukes in refers to Leger who is said to have found in 50 cent of the natives of the East- India is both meagre and conflicting. The only eggs per systematic investigation that has been made Coast of India', but Chandler did not find in connection with helminthic infections is by even a single case of clonorchis infection in Chandler (1928) who states in his detailed any of the provinces, although his investigation covered practically the whole of India includ- * the east coast. a few cases Read at the Indian Science Congress, Bombay, 1934. ing Only sporadic of fluke infections other than clonorchis were found in practically every province except Burma. Fasciolopsis buski is the one which was commonly met with and it was found almost in endemic form in some parts of Assam. McConnell (Castellani and Chalmers, 1919) reported two cases of opisthorchis infection among Indians in Calcutta and one of clonor- chis in a Chinese who apparently got the infec- tion in China, and hence this was not an indi- genous infection. Knowles (1923) reported a case of clonorchis infection in Assam, but Chandler believes that it was really a case of opisthorchis which is a very common parasite in cats and dogs in Calcutta and also in other parts ' of India, especially in eastern India. Besides, the clinical history of the case, as given by Knowles, is against the possibility of any such infection. Byam and Archibald mention that Acton found two cases of clonorchiasis in Mesopotamia among Indian soldiers. On refer- ring to the paper it is seen that Acton (1919) found ova of Clonorchis endemicus in two and ova of Heterophyes heterophyes in one out of about 3,000 Indian soldiers. As there is no reference in the paper to the condition of the patients in whose faeces the ova were found, it may be assumed that the clinical features of these cases were not in any way suggestive of clonorchiasis, otherwise they would have attracted the attention of a keen observer like Acton and found place in his paper. The eggs found in the stools were probably opisthorchis eggs. As clonorchis is very common in China, Japan and other Far Eastern countries, there is a like- lihood of cases occurring in Burma but Chandler failed to detect any. Manson in describing the geographical distribution of the liver flukes has mentioned India as one of the countries where it is found, but no genuine indigenous case, con- firmed either by finding the flukes or by clinical features, has so far been reported. In Bihar, only two cases of Fasciolopsis buski infection were found by Chandler in the districts of Singhbhum and Ranchi and by other obser- vers in Monghyr and Patna. The case I am reporting here appears to be one of Clonorchis sinensis infection and was found in Patna. The patient, a Muhammadan male, aged 23 years, consulted his doctor for treatment of anaemia, enlarged spleen and liver and occasional attacks INFECTION IN INDIA : BAGCHI 319 .Tune, 1934] CLONORCHIS with me in a permanent preparation made by me a few months ago in the Liverpool School ^ars 0^.^s illness, The classification of the Clonorchis into n w*th all the features of infan- genus tilAm ' T1! C. sinensis and C. cndemicus is not based on was an of the bowels rK i re, irregularity reasonable cannot be distin- with grounds. They ahn o 11-ala a^ernating constipation?and and are identical. a miId attack of a fewguished morphologically months w jaundice The of clonorchis or the inten- was to have been pathogenicity suffpr^n. ? i suspected 10m of the signs and symptoms depends upon ? sity losfnm ^ala-azar or malaria with ancy- as the number of the parasites invading the hosts of hie. explication. The examination mSIS]?? and not on any features. The ^le blood corn- morphological Dlpfplt/ x? ^Mowing picture of any distinction between the <^ the questionor making - possibility of malaria eal a a z a^,e^a two on grounds of pathogenesis is not reason- and has not been Manson. Red blood able, accepted by cells .. .. 3.37 millions from the characteristic features of these ute blood Apart cells .. 10,800 ova the of this fluke is also a P0I3 pathogenicity niorphonuclears .. G6 per cent determining factor in establishing its identity. .. lymphocytes .. 18 ? ? is found as a parasite of cats Large Opisthorchis mononuclears .. 4 ? and dogs in India and other places, but has Eosinophiles . 12 not been known to produce any disease. has so far not been found in India andr^niL--rP?cIesand (microcytes^ Heterophyes poikilocytes) .. present one found Acton in Indian aemog obin (excepting by # _ .. 45 per cent soldiers in as Colour index Mesopotamia, already stated), q gy and is not pathogenic. Clonorchis is undoubt- edly a pathogenic parasite and has not yet Parasites were found and the scrum 1?;!'f1^ai been detected in animals in India. The des- The nHn kala-azar were all negative,cription of the signs and symptoms of clonor- of his faces ,nofinal- The examination chiasis, as given by Manson, corresponds with GfbIiaS w ova bookworms even iftn any of this case to a remarkable extent, but the patient li most method ile exacting search by Lane'sdid not at the time of investigation develop "f0m on other the fi V d^s- But the hand, any anasarca, ascites, or intractable diarrhoea, an ovum nf x!arnination of the faeces showed which are generally found in very advanced ODernnlnm ,WI? colour with characteristic cases that end fatally. The signs and symptoms S aPe- As more were case indicate an infection of it was nnf*1 expected, of this moderate measured and was thrown and the treatment to so and Venn of away intensity given him not examination of the same stool far seemed to have retarded the onset of fur- did c'l 10W of f-pppo' a?y .niore ova. Another sample ther complications for the time being. The obtained after two days and a of these cases is one of their thoroimb SCai'c chronicity special Was made for these ova but features and even the worst cases on for nothing aS drag next f0Und- T1^ third sample on the several years before they die. In the absence dL a^? exam in WrlS negative. The fourth of other causes, the aniemia, the physical signs three nVn ^ a{ a couple of days more showed and the blood picture of the patient could also measurpd slides. They were carefully be explained by ancylostomiasis, but when four ln,^oa^ about thnan them were found to be of examinations of fseces during the course of a size with slight difference in week did not show a single hookworm egg, even length onlv^iIi:[e 27.6 j)V A" average dimensions were by the most reliable method of examination, the figures fl' or 28 k-y 16 /x in round possibility of hookworm infection can safely be excluded. rp 1 the life of the the ?^laPe and size of these ova are Considering history flukes, Quite^pbn,011^ac of source of infection of these sporadic cases of it miv h ,ristic Clonorchis sinensis, but clonorchiasis in this country is rather chis n0t^ h?*e that the ova of clonor- mys- Lty and look terious, for the people of India seldom take 'i very much lil-n 10rCj** Si heterophyes cann?t be differen- uncooked fish. It has been proved in China tiated un C1 always Cr 1 e that certain water in which the cercariae diap-nnc'c microscope ; the specific plants are for the be made satisfactorily by encyst also responsible spread of ??,n]y exaS?nCan tlukes themselves. In flukes in man and Chandler traced the infec- this casp J1 -^e in tion of F. buski in Eastern Bengal to the eating of thp could be detected any ' 1 ' ootv^0,Parasites of or and 1 was to panifal' singara (Trapa bicornis) faU on fae-ces' obliSed 1 back +i?f which is taken raw and commonly peeled . by the ov? in it microscopic examination of 1t the teeth'. It is therefore eir details and to compare them quite possible that With" VPical1 clonorchis ova, which I had had 320 THE INDIAN MEDICAL GAZETTE [June, 1934

1 singara' plays also the same part in infecting men with clonorchis.

Summary The flukes that infect men are very rarely found in India. Chandler reported a few sporadic cases of F. buski infection in different provinces, but he did not find a single case of clonorchiasis anywhere in India or Burma, although it is very common in China, Japan, Korea and other Far Eastern countries. McConnell found clonorchis in a Chinese in Calcutta. Knowles reported the finding of the eggs of clonorchis in the faeces of a man in Assam, and Acton in two patients among the Indian soldiers in Mesopotamia, but no specific diagnosis was made, either "by finding the flukes or by clinical history. The case referred to in this paper is an indigenous one developing signs and symptoms suggestive of clonorchiasis, and typical ova were found in his fasces. The ova of clonorchis, heterophyes and opis- thorchis all look alike and it is very difficult to differentiate them under the microscope. In China, Japan and other eastern countries the practice of taking uncooked fish spreads infection in man. Certain water plants in China have also been found to harbour encysted cercarise. Chandler traced infection of F. buski ' ; to eating the common waternuts or singara (Trapa bicornis) in Eastern Bengal. It is probable that this waternut which is found all over India may be the source of infection in the sporadic cases of clonorchis and other fluke infections.

References Acton, H. W. (1919). Indian Journ. Med. Re*., Vol. VI, p. 601. Byam, W., and Archibald, R. G. (1923). The Prac- tice of Medicine in the Tropics. Vol. III. Henry Frowde, and Hodder and Stoughton, London. Castellani, A., and Chalmers, A. J. (1919). Manual of Tropical Medicine, p. 577. Third Edition. Bailliere, Tindall and Cox, London. Chandler, A. C. (1926). Indian Journ. Med. Res., Vol. XIV, p. 179. Chandler, A. C. (192G). Ibid., Vol. XIV, p. 481. Chandler, A. C. (1927). Ibid., Vol. XIV, p. 733. Chandler, A. C. (1928). Ibid., Vol. XV, p. 695. Knowles, R., Chopra, R. N., Gupta, J. C., and Das Gupta, B. M. (1923). Indian Med. Gaz., Vol. LVIII, p. 470. Manson-Bahr, P. H. (1929). Tropical Diseases. Cassell and Company, Ltd., London.

[Note.?The evidence that this is a case of clonorchis infection is not at all conclusive as it appears to have been based on the study of three eggs. Up to the present no case of endemic infection with this fluke has been definitely proved in India. The suggestion that sporadic infections of clonorchis may be transmitted, like Fasciolopsis buski, by cercarise encysted on the corm of Trapa bicornis is not in accord with the known life history of this parasite, as a second intermediate host (a fish), in which the cercarise encyst, is needed.? Editob, I. M. G.]