NationalLibraryOfScotland/medical-history-of-british-india huggingface dataset:
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microscope and systematically examined. Care must be taken
that only a very small quantity is placed on the slide, as recog-
nition of the ova is almost impossible in a thick layer. A
better plan is to place a small quantity (a mass about the size
of a pea) of the material in the bottom of a test tube which has
been provided with a good cork, about a couple of inches of
1-20 solution of carbolic acid is then added, and a single
drop of some analine dye, such as magenta. The cork is then
inserted, and the contents well shaken and allowed to stand
for a few minutes. A pipette is then passed down to the sedi-
ment, but not quite to the bottom, and a small quantity of the
sediment allowed to run in and transferred thence to a slide.
The use of the carbolic acid does away the small disagreeables
of the examination, and the dye is useful in distinguishing the
ova from the other bodies. They themselves are little if at all
stained, except by a much more prolonged action of the dye,
but nearly everything else found in dejecta takes it up greedi-
ly, so that the ova are the more readily made out by the
contrast of remaining unstained.
The points of distinction between the ova of Doclimius
duodenalis and those of other human nematodes have already
been described, and the only other ova likely to be met with
are those of tape-worms and flukes. All of these, however,
want the clear belt which surrounds the yelk. Moreover, the
ova of all human flukes are much more segmented, as also is
that of- Bothriocephalus latus, while those of Tcenia saginata and
T. solium are smaller and quite spherical, instead of ovate. A
much more frequent source of difficulty, however, are coccidia,
a species sporozoon, which is very commonly found in immense
numbers in the dejecta of patients affected with anchylosto-
miasis. Their occurrence is not constant, but is so common
that they are to be found in the larger proportion of cases.
In healthy subjects, I have not, as yet, met with them, and the
instances where they have been present in the largest numbers
have usually been advanced cases. What their connection
with the disease, if any, may be, is difficult to say, but they
certainly form no essential part of it, as they may be quite
absent in even the worst cases.
The number in which they may be present is astonishing,
and, estimated in the same way as was done in the case of ova,
many millions may be passed in the day, so that, even in the
diluted material, half-a-dozen may be found in each microsco-
pic field. They vary a great deal in size, but are generally
very much larger than the ova of Doclimius, averaging about
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YJL-^ incli in diameter, so that it is only in the case of small
specimens that any doubt could arise. Besides varying much
in size, they are by no means uniform in shape, which, while
occasionally regular, is more often unsymmetrical, differing in
fact from ova much in the same way that potatoes do from
eggs. Each coccidium contains from 4 to 12 or more psoro-
sperms, and, in small specimens, where the outline chances
to be oval, the resemblance to Dochmius ova is very close.
As, however, they rapidly become intensely stained in even
very dilute solutions of analine dyes, no difficulty will be
experienced in distinguishing them if the second plan of exam-
ination be employed.
The occurrence of organisms of this class in human alvine
discharges has been, previously observed byKjellberg andEimer,*
and it is doubtful whether they should be considered iden-
tical with C. oviforme, found in the liver and intestinal canal of
rabbits, or not. These organisms sometimes cause fatal illness
in rabbits, and Leuckart'j 1 gives a fatal case in man, reported
by Gubler in Paris. The account of the case, however, reads
suspiciously like one of anchylostomiasis, and it is possible that
ihepsorosperm nodules found in the liver in this case may have
been but an accidental complication, especially as the occurrence
of such nodules in the tissues of animals is not inconsistent with
health. The date of the report (1858) is prior to the St. Gothard
tunnel outbreak of anchylostomiasis, which first brought an-
chylostomiasis, as an European disease into prominent notice, so
that the presence of anchylostomes would have been unlikely
to attract notice, even if present. The curious point is that,
though specially sought for, no psorosperm nodules could be
fqund in either the liver or bile ducts in the cases I have exa-
mined, but it must be remembered, however, that a considerable
number might be present, and yet escape notice. Another curious
circumstance is that these organisms maybe associated with other
epidemic diseases, for example Oobbold found that they were
almost universally present, in enormous numbers, in the flesh of
animals which had died of rinderpest, J and Leuckart found them
in the intestine of triclmized dogs, but neither author attributes
any pathological importance to their presence in either of these
cases, and, in the present instance, I hesitate to consider their
*Verchow's Archiv, Pathol. Auat, Bel. XVIII.. page 527, 1860 ; vide
also E. Hoyle's translation of Leuckart's " Parasites of Man." Young
J. Pentland. Edinburgh, page 221.
t Loc. cit., page 322.
I Cobbold: " Parasites." J. A. Churchill, London, 1879, page 278.
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appearance as more than a coincidence, though, when present,
their attacks on the epithelia of the intestine can hardly fail
to aggravate the existing dyspepsia. However^ whatever their
significance, they are extremely common in cases of anchylos-
tomiasis, whether under the name of kdla-azdr in villages, or of
beri-beri in tea-gardens, so much so, that, at one stage of the
investigation, before I had satisfied myself of the wide diffusion
of anchylostomiasis, and its adequacy to account for all the facts
of the case, I was inclined to suspect that they might have some
casual connection with kdla-azdr. The coincidence, however, is
too common to be purely accidental, and it is possible, though I
have no facts to support the surmise, that the germs may be in-
troduced into man through the agency of the embryonic anchy-
lostomes, and that their frequency in man may depend on a
corresponding prevalence of psorosperm parasitic disease in the
free stage, anchylostom.es, in which case, one stage of the life
of the psorospermia would be passed in the Ehabdites and
another in the intestine of man. If this be the case, they
must be a distict species from liver coccidia, and their non-
occurrence in that organ is explained. It will be seen, there-
fore, that, though their presence forms a possible source of
fallacy in the microscopical examination of dejecta for ova, their
frequent association with anchylostomiasis renders it highly
probable that when they are present, ova will be found also.
In any case where, in spite of suspicious symptoms, ova
cannot be divscovered, the test of cultivation described on
page 72 should be resorted to, and I do not consider that
the absence of the parasites can be considered as proved until
resort to this method has been adopted.
The utterly insufficient grounds on which the absence
of the parasites has been assumed by various observers has
already been adverted to, and the commonest of these is the
non-discovery of the worms after the exhibition of thymol.
In most cases the examination has been nothing more than
a casual glance at the dejecta en masse. I can only say that,
however many may be preseilt, it is in the last degree impro-
bable that any will be discovered by so casual a method of
examination, as their colour and small size makes detection
in this manner almost impossible. The only safe plan is to
place the mass on a loose surface of muslin, and to let water
run on it for a considerable time (about an hour). At the
end of this, a small quantity of quite inoffensive material,
consisting of the worms, and larger particles of undigested
matter will be left, but, even now, owing to the large proper-
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tion of the food that passes through the bowel unaltered,
considerable numbers may be present, and yet not be visible
except under special circumstances, and to ensure their detec-
tion, the mass should be transferred to a shallow glass vessel
placed on a dark ground, and then carefully searched over, by
slowly stirring it, so as to successively pass the whole mass in
a thin layer over a portion of the dark ground. Such a
proceeding necessarily involves an expenditure of time and
trouble rarely at the disposal of medical men engaged in their
usual work, and what I deprecate is, not that the trouble has not
been taken to examine thoroughly, but that the most casual
examination is made the basis of most positive assertions as to
the absence of the parasite. It is just because its discovery
is no easy matter that its presence has so long been over-
looked. Only once have I succeeded in discovering the
worm by mere casual examination, and that in a case where
they were exceptionally numerous.
From what has been said, the immense importance of
making a diagnosis early in the case will be at once appre-
ciated. When circumstances will permit of such a course of
action, we should never wait for the patient to seek medical
aid, but should examine and make our diagnosis before he
confesses himself to be ill. In ordinary practice such a plan
is unfortunately impracticable, but 011 tea-gardens it should be
quite easy to carry out. I feel convinced that the only
thorough way of eradicating the disease from these establish-
ments is by adopting the plan that has proved so successful in
dealing with scurvy in military and prison practice. Just as
is the case with anchylostomiasis, scorbutic mischief may go
very far indeed before the patient is so ill as to be compelled to
seek medical aid, and it has long been recognized that the only
safe method of dealing with the disease is the early detection of
cases by periodical systematic medical inspections. Luckily,
just again, as is the case with scurvy, a diagnosis, good enough
for all practical purposes, can be made at a glance, so that, if
the medical attendant time his visit at the usual weekly muster,
it need not prolong that process, as he will be able to make
his examination of the men in much less time than it will
take the manager to pay them.
As the disease is essentially a chronic one, there would be
no need for making such an examination every week, and
once a month would probably be sufficient. All cases detected
should at once be sent to hospital, and where the diagnosis is
doubtful, it might be supplemented by microscopical examina-
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tion, though, this will rarely be required, and in all cases,
where the diagnosis appears sure, the men should at once be
treated with thymol. Taken at this stage, before the patient's
digestive powers have become thoroughly undermined, the
treatment need only involve two or three days' absence from
work, whereas, if the disease have once gained a fair hold, a
prolonged convalescence is inevitable, and may require months
to complete, during which the labourer is useless to his
employer, and necessarily becomes too poor to supply himself
with the liberal allowance of nourishing food indispensable
to his recovery. Hence, I repeat, every effort should be made
to expel the worms while -the patient is still capable of
digesting his ordinary food. Another advantage is, that the
administration of thymol to a man whose strength is but little,
if at all, diminished, is a. trifling matter, while, if given to
advanced cases it may even accelerate the fatal termination
of the malady. By acting in this way, too, we put a great
check upon the spread of the disease, for it is just these
early cases, who are still able to move about freely, that
spread the ova of the parasites far and wide over the country,
and every worm killed means the destruction, or rather the
prevention of the birth, of thousands of the infective embryos.
Moreover, from all I have seen and all I can gather from gentle-
men engaged in tea-garden practice, who have had immense
experience in the treatment of the disease, there can'be no doubt
that the treatment of advanced cases is entirely unsatisfactory,
and that we can rarely hope for a cure when once the fatal
destruction of the digestive powers has been allowed to progress
to any great extent,* and hence every effort should be concen-
trated on the detection of cases while still in their earliest stage.
There is one symptom which has everjnvhere attracted
considerable notice in anchylostomiasis, which requires some
notice here. I refer to geophagy, or earth-eating. It must
not be supposed that this symptom is pathognomoiiic of the
particular parasite with which we are at present concerned.
It is a common symptom of helminthiasis of all kinds, and
is not even peculiar to man. The same habit has been noticed
in elephants affected with flukes (masuri) as well as in horses
affected with strongyles and other parasites.
It is difticult to see why such a perverted appetite should
be caused by the presence of entozoa, especially as it is by 110
means always traceable to short-commons, combined with
increased appetite ; as the victims of the habit will eat earth,
even when plenty of proper food is easily obtainable, and even
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when the appetite for natural articles of diet is but small. As
is well known, a similar habit is common in pregnant women,
and here can only be owing to a sort of moral reflex to the
stimulation of the uterine afferent nerves, though why the
impulse should pass on to the higher centres, instead of
manifesting itself in the usual way in a current propagated
along the corresponding efferent fibre is a matter on which
we can form no guess. Probabty, the phenomenon is here
owing to a reflex of a similar kind, initiated by stimulation
of the intestinal afferent nerves. However that may be, the
habit is very common among tea-garden coolies, and also
in kdla-azdr-atrickQiL villages, the inhabitants of which recog-
nize it as one of the most characteristic symptoms of kdla-
azdr. The coolies do not seem at all particular as to the
kind of earth used, and a specimen, recently received from
Chiknagool, contained a quantity of gravel, as well as some
remarkably rough pebbles of coarse sandstone, and advanced
cases, who are too weak to walk easily, will devour the
mud from the floors and walls of the hut. The Assamese
villagers seem to be more particular, and prefer a smooth
clayey soil, which they regularly bake into a sort of biscuit,
having a peculiar and extremely disagreeable smell, which
they call chikur. The cooking seems to be rather of the
nature of drying than baking, and I should doubt if the
whole mass is constantly raised to 140°F. This peculiar habit
was first brought to my notice by my Assamese Hospital-
Assistant in one of my visits to Paru, where he got me some
of these earthen biscuits from a house where Jcdla-azdr was
very bad. I gather from him that certain medicinal powers
were attributed to them, but he seemed to think this was
rather an excuse for eating them than otherwise, and that, as
he expressed it, they look upon them as " a sort of luxury."
It is perfectly obvious that the existence of such a habit
offers great facilities for re-infection by the ingestion of
quantities of earth which may contain infective embryos, and
such an occurrence is especially likely to occur in cases that
are too far gone to move far from their beds in search of this
extraordinary provender. As is well known, this habit is to
be met with, in isolated instances, all over India, and I can-
not help suspecting that microscopical examination of the
dejecta in such cases would lead to unexpected results.
When present, the desire seems almost uncontrollable. In a
case which came under my care at Hoshangabad, the patient,
an inmate of the Society of Friends' Orphanage there, and par-
C -" 15 )
ticularly well fed and cared for, was bedridden from hip-
joint disease. In spite of all entreaties and remonstrance, she
insisted on picking out and eating plaster from the floor of
the ward. Ultimately, the lady in charge of the case took to
tying her hands to the bed, and then, in spite of this and a
long splint and weight, she would contrive to wriggle the
upper part of her body off the bed and to grub up the plaster
with her lips and teeth, whenever she was left alone for a
few moments. My attention had not then been drawn to the
connection between earth-eating and helminthiasis ; but, look-
ing back upon the case, I now feel little doubt that the presence
of some parasite was the cause of this extraordinary longing.
The only way of dealing with it is obviously by the
expulsion of the parasites. Its existence is an added danger
to those already caused by parasites, as death has been
known to be caused by exceptionally large meals of this
unnatural kind, and I can recall a case where this actually
took place, in my own practice, in the case of a grass-
cutter, while I was employed on regimental duty in the Punjab.
This man had swallowed several pounds of earth, but even
when the habit exists to but a small extent, it must greatly
aggravate the dyspepsia which forms so important a feature in
cases of anchylostomiasis. The difficulty of dealing with it, in
actual practice, may be judged from the case already described.
In the matter of treatment, I have little to add to what
has already been made public by previous writers on the
subject. There can be no doubt as to the efficiency of thymol
in expelling the parasites, but I am anxious to emphasize
the necessity of adhering to the dosage* recommended in the
Sanitai-y Commissioner's circular on the subject. I have
found a great deal of variation in the practice of different
people in this matter, with, as a rule, only the most vague
general opinions assigned as the reason for so doing.
For example, I found that the Assistant-Surgeon at Dibru-
garh was employing doses of only a few grains, and, on
closely questioning him, the only justification he could urge
for the practice was, that he thought the patients were
improved, but that he had never attempted to ascertain
whether the worms were expelled or not, b}*- even the most
casual inspection of the dejecta. Probably, his real reason
was the tendency to hoard up "Europe medicines," which
* See paragraph 49, Annual Sanitary Keport of Assam for 1888. See
also paragraph 48, linos 8-13, Assam Annual Sanitary Report for 1889,
which recommends thymol first, and then purgatives.
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amounts almost to a mania in many medical subordinates.
As has already been remarked, my clinical opportunities
have been but scanty, but I have tried these small doses in
several cases, and have never found them expel a single
worm, and, moreover, I treated some of the cases that had
already been treated with these small doses in the Dibrugarh
Charitable Dispensary, with the ordinary doses, and expelled
the worms in such considerable numbers that it was perfectly
clear that, whatever effect the small dose may have had, it
was entirely inadequate, and for practical purposes it may
be taken as certain that the employment of the drug in such
small doses as 3 to 4 grains for adults is nothing better than
a purposeless waste of an expensive drug.
The smallest dose with which I ever succeeded in getting
any effect whatever in an adult was ten grains thrice repeated,
but the dose was clearly inadequate, as many worms were left
behind. The usual routine dose of 30 grains thrice repeated
very commonly expels every single worm, as has been ascer-
tained in several cases where the subsequent death of the
patient enabled the matter to be established beyond doubt. On
the other hand, even with this dose, I have often found consider-
able numbers of the parasites left behind, as evidenced by the
uninterrupted continuance of ova in the dejecta. However,
by employing a different plan of exhibiting the drug, I have
several times obtained excellent results with thrice repeated
twenty-grain doses, and am inclined to think that a great
deal depends on the manner in which it is administered.
Thymol is a body very little soluble in water, and its action on
the parasites appears to be, by contact with the solid material,
little or none of it appears to be absorbed into the circulation,
under ordinary circumstances, so that by far the greater part
of the drug passes unaltered with the dejecta. Owing to this, it
is quite evident that a dose of 20 grains, carefully triturated,
may be far more effectual than one of 30, which has been
but coarsely powdered. Unfortunately, thymol is anything
but easy to powder, and to do so thoroughly involves a great
deal of personal discomfort, in the way of sneezing and lachry-
mation, to the compounder, so that, with the very inferior-
agency we are able to employ in such work in India, it is by
no means surprising that the job is often very badly done,
and, as a matter of fact, I have often, in searching for the
worms, recovered a large portion of the dose from the dejecta
in comparatively large crystals, often reaching the size of
a No. 8 shot. Putting aside then such absurd doses as 3 or
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4 grains, the effect of a dose will depend much more on the
fineness of the particles of the drug than on the actual weight
employed, and so, as at present administered, comes to depend
mainly on the endurance of the compounder, and the vigour
of his arm. There is, however, not the least reason why this
should be the case, as there are other means than mechanical
trituration available, by means of which thymol can be reduced
to a much finer state of division than can ever be obtained by
the agency of pestle and mortar. Though so little soluble
in water, thymol is almost indefinitely soluble in rectified
spirit, and can be conveniently kept in spirituous solution for
dispensing purposes. If some of this alcoholic solution be
poured into a relatively large bulk of water (say, a drachm of spi-
rituous solution into an ounce of water), a milky emulsion at once
results, which consists of minute oily globules, not much larger
than those present in milk, and it is in this form that I would
strongly recommend the drug to be administered, if we would
wish to secure uniform results from uniform doses. If, however,
such an emulsion be allowed to stand for a while, the circular,
oily globules run together with larger ones, and, after attain-
ing a certain size, resume the crystalline form, and then, though
the crystals are usually but small, the advantage of over tritu-
ration is only one of degree. The addition to the water of muci-
lage or rice conji will retard this change for some time, but not
sufficiently long to admit of the drug being sent out to patients
in this form. Hence, the alcoholic solution should, wherever
practicable, be only added to the emulsifying vehicle imme-
diately before administration, and where the necessity of sending
out of doses to patients renders this impracticable, it should be
made with hot conji of such strength as to gelatinize when cold.
I believe that 20 grains of thymol administered in this
way will be at least as effectual as 30 given in the usual
fashion. To go into practical details I would recommend the
following formulas :—
(a) Stock solution of thymol—
Thymol
grains 480
Sp. rect
ounces ii.
Dissolve the thymol in the spirit, and add a sufficiency of
rectified spirit to make up to ounces iii. Twenty grains of
thymol are contained in each drachm of this solution.
(b) Vehicle for administration—
Strong mucilage of acacia or dextrine
ounces ii.
Glycerine
drachm one-half.
Water
add ounces ii.