NationalLibraryOfScotland/medical-history-of-british-india huggingface dataset:
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At the time of administration add one drachm of the stock
solution of thymola to ounces ii. of (5), shake well, and adminis-
ter at once.
Another point in connection with the use of thymol
which requires some notice is the concurrent administration
of purgatives. It is usually recommended to commence by
the administration of a purgatiye, and also to follow up the
doses of thymol with a second. Thus, treatment of a very
active character, consisting in all of five doses of very active
drugs, is extended over several hours, and the whole proceed-
ing becomes so heroic that it becomes quite beyond the endur-
ance of advanced cases, and, in some cases that have come
under my observation, I am convinced has accelerated the
fatal termination, though doubtless these were cases which must
inevitably have died sooner or later whatever treatment had been
adopted. I must confess that I am unable to understand the
rationale of the first purgative dose. The intention is, I suppose,
to obtain a free field for the thymol in the shape of an empty
bowel, and, in the case of parasites whose habitat is the
lower bowel, its administration would be rational enough. But
the duodenum and jejunum, as the name of the latter indicates,
never contain sufficient food to interfere with the action of the
drug, and where we have to deal with Doclimius duodenalis
its administration can only be needless, and will probably be
prejudicial, for the irritating effect of the purgative will great-
ly increase the amount of mucus in the parts of the bowel
over which it has passed, and this mucus will be a much more
effectual bar to the action of the thymol than the presence of
a considerable quantity of food. Besides, as far as these parts
of the intestine are concerned, the withholding for a few hours
of all solid food will be more effectual than all the purgatives
in the pharmacopsea.
A previous abstinence from solid food forms part of the
ordinary treatment, and I have been unable to trace the least
additional advantage in the additional administration of a
preparatory purgative in cases treated for comparison 011 the
two plans. In the case of subjects in the initial stages of the
disease, picked out by inspection, it is probably a matter of
little moment which course is pursued, though I believe the
preparatory purge to be in any cases needless, but, in the cases
we are more commonly called upon to treat, especially in
dispensary practice, every additional strain on the patient's
strength, and especially on his digestive powers, becomes a
matter of serious import, and, when diarrhoea is a prominent
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symptom of the fatal dyspepsia of the disease, it becomes a
question whether the second purgative should not also be
dispensed with, which, where the patient's forces are at all a
low ebb, must be answered in the affirmative. As, however,
has been already remarked, the action of the drug seems
often to stupefy rather than kill the parasites, a subsequent
purge is clearly indicated wherever the patient's strength
will admit of it, lest the parasites should recover their
vitality before they have been expelled from the intestinal
canal. The danger of this is, however, perhaps more
apparent than real, as, provided the narcotized parasites had
been passed beyond the jejunum, the new habitat would be so
unsuitable to them, that it is highly improbable that they would
be able to establish themselves in these lower parts of the
intestinal canal. Hence, wherever there is any doubt of the
patient's ability to bear vigorous treatment, I should
personally incline to the exhibition of thymol alone, except in
cases where actual constipation is present, where the long
retention of the drug in the system might lead to a larger
absorption than is desirable. On the whole, as the mildest
of all purgative agents, good castor-oil is probably the
best drug for our purpose, and has only one disadvantage,
in the fact that .the presence of the oil in the dejecta renders
the detection of the worms a matter of considerably greater
difficulty- than when saline purgatives have been employed.
The way, indeed, in which it clings to the worms strongly leads
one to suspect that its use as a preparatory purgative, so far
from being advantageous, may defeat our object by giving
the worms a protective coating, and so preventing contact with
the thymol.
While deprecating the purposeless waste of thymol by the
exhibition of absurdly small doses, it is to be noted that there
are many indications that a dose of 30 grains is about as large
as can be safely given, and that in advanced cases the practice
of repeating this dose three times is not unattended with
danger. In particular, I recall a case observed by Dr. Mullane
and myself inGauhati jail. The patient, who, while exhibiting
unmistakable symptoms of anchylostomiasis, seemed by no means
in the very last stages of the disease, was given thymolin the usual
way. The worms were expelled in fair numbers, but the man.
died within 48 hours of the treatment. On post mortem examina-
nation, it was found that not a single worm had escaped the action
of the drug, but that the whole length of the intestinal canal was
in a state of active congestion, and there can be no practical
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doubt that the man's death was accelerated by the treatment
adopted. Another reason for thinking that, in the customary
dose of 90 grs. we are closely approaching the limits of tolera-
tion of the drug, is to be found in the fact that I certainly
succeeded in poisoning a horse with a dose of 2-J oz. This
quantity was, it is true, given in a special manner, and in a single
dose, but it is not much in excess of the customary dose for
a man, proportionally to the weights of the subjects, especially
when we remember that the whole 90 grains is usually in the
intestine at once, no motion of the bowel commonly taking
place until some time after the administration of the last 30
grains. I had some time previously given the animal 1^ oz. in
three ^ oz. doses without producing any particular symptoms
beyond the expulsion of a number of parasites, but it died
within 6 hours of the administration of the larger dose. For
about an hour after receiving it, the animal fed naturally, and
seemed under no inconvenience, and I then went away, but,
shortly after this, he became restless and weak, and laid down in
his loose box and soon became unable to rise. He broke out into
a " cold perspiration," and died apparently in a faint, having
at no time exhibited much sign of pain. For the later symp-
toms I have to depend upon the description of Mr. Brown, the
Transport Conductor here, who is, however, a very acute ob-
server of animals. The animal seems to have died from cardiac
failure, and the symptoms bear some resemblance to those of
carbolic acid poisoning, as, indeed, might be anticipated would
be the case from the chemical constitution of the drug. It
should be added that the animal, a 13-2 Bhutia pony, though
excessively weak and ansemic from the effects of Sderostomum
tetracantham, a parasite which extracts blood from the mucous
membrane of the lower bowel of equine animals, in exactly
the same way as is done for the human small intestine by
Dochmius duodenalis, was by no means in a dying state, and
had walked 1^ miles just before without showing much distress.
Any attempt, therefore, to increase the customary dosage should
be made with the greatest caution.
The scantiness of my clinical opportunities prevented
my making many experiments with other drugs than thymol.
As to the efficiency of this drug there cannot be the least
doubt. It expels round worms more surely than santonine,
and, as I am told by Dr. Hancock of Dibrugarh, is far more
efficacious than male fern in the treatment of tape-worm. I
have myself seen it expel flukes, and there can be no doubt
that it is an almost universal vermifuge. Hence the most im-
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portant point was to, if possible, ascertain the best way of
administering it, and the examination of other drugs was a
secondary matter. With salol, some success was obtained, but
it appears inferior to thymol, and, as it is somewhat dearer, no
advantage would be gained by its substitution. Picric acid
had no effect whatever, neither, as far as concerned anchylos-
tomes, had santonine. I meant next to have tried some of the
less soluble analine compounds, but it would hardly be justifi-
able to try an experiment of this sort on any but an early case,
and such cases I have not been able to obtain for treatment.
Moreover, in the entire absence of information as to the safe
dose of these substances, one would have to proceed very cau-
tiously, so that a large number of tentative administrations
would be necessary before one could be sure of one's ground.
The idea that they might be useful is based on their known
antiseptic powers ; but, after all, the difficulty lies not in the
expulsion of the parasites, but in the restoration of the digestive
powers, and as no drugs can ever be expected to effect this,
the whole art of treatment resolves itself into the early detec-
tion of cases.
COMPLICATIONS OF ANCHYLOSTOMIASIS.—Other parasites.—
probably to the peculiarly favourable nature of the climate
for the development of the free stages of nematodes and
other parasites, Assam is a perfect hotbed for parasites,
man and animals being alike affected, with an universality
that can hardly be surpassed elsewhere.
It is excessively rare to find an Assamese entirely free
from parasites, and, so far as my observations have gone, it
seems almost equally rare to find it the case in an Assamese
animal, whether free or domesticated.
In man, besides Dochmius duodenalis., the following parasites
were met with:—
Trichocephalus dispar.— It is exceptional to meet with an
Assamese who does not harbour this parasite. So far as my
own observations go, it appears to be almost confined to the
coecum, and as many as a hundred may be present. It
buries the long filiform aenterior, part of its body in the
mucous membrane, never penetrating deeply, but burrowing
along, barely beneath the epithelium, and subsists probably
on the intercellular plasma of the tissues surrounding the tunnel
it makes. Sometimes it does not seem to cause much irritation,
but at others an angry blush marks out the tunnelled line ;
and I have so often found it coiled up within ulcers of a dysen-
teric character that a causal connection between parasite and
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ulcer may be strongly suspected. It, or a species anatomically
identical, was present in all five of the specimens of Macacus
rhesus that I have examined, so that the eggs must be very
widely diffused over the country. Its presence does not
appear to be incompatible with apparent health; but if, as
appears probable, it be capable of causing ulceratioiis of the
gut, it is evident that, under certain circumstances, it may by
itself cause dangerous symptoms, and at best it cannot fail to
do something to help the destruction of the digestive powers
initiated by anchylostomiasis.
The life history of this parasite is involved in doubt, but
the general opinion seems to be that infection is direct, i.e., by
ingestion of eggs. The structure of the envelopes of the ova
are somewhat in favour of this view, the shell* being hard, and
remarkably resistent to ordinary chemical agencies, a fact
which leads one to suppose that they are designed to persist
a considerable time as ova, and that some special agency, such
as that of the gastric juice, is required to set them free.
Leuckart* states that they require a temperature of not less
than 72° F. for their development, and that the process is rarely
completed under a year. When deposited, the ova, which are
of deep red brown colour, of elongaed oval form, and possess-
ing a peculiar sort of knot at each pole, sjiow no signs
of segmentation. In a cultivation started five months ago,
on the same plan as those of Dochmius ova, segmentation of
the ova commenced only five days after the commencement
of the experiment. The yelk divides into two very unequal
parts, and then the larger segment divides into two, and after
20 days, the morala stage was reached; but at present many
of the eggs are still very backward, only a few contain em-
bryos, and I cannot be certain that any have hatched out.
The temperature has rarely exceeded Leuckart's minimum to
any great extent, and has often fallen below it during the rains.
A similar cultivation was kept for about a fortnight at a tem-
perature ranging from 80°—104° F., but no particular hastening
of the process took place during this period, and the temperature
regulator worked so ill that a continuation of the experiment
had to be abandoned. A practical difficulty in this investi-
gation is that of getting specimens of dejecta containing Trich-
ocepJialus ova alone. On the other hand, certain cultivation,
conducted in the open air and containing, inter alia, Tricho-°e
plialus ova, have been found, after a week or so, to contain
* Hoyle's Leuckart's " Parasites of Man," I., page 56.
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a peculiar rhabditis, which is certainly referable to no stage
of Dochmins, and in which the oesophagus runs through a
peculiar cord of cells, the structure of which strongly recalls
that of a similar structure found in the entozoic Trichocephalus,
but, at the same time, other cultivations designed specially with
the object of obtaining such rhabdites entirely failed to show
any, so that the conditions, even supposing them to have been
in these instances accidentally complied with, involve some-
thing not plainly apparent, possibly an invertebrate interme-
diate host. It is clear, however, that more time than as yet
has elapsed is necessary for the thorough investigation of the
life history of a parasite about which there is good authority
for expecting a development extending over an entire year
within the egg alone.
Trichocephali offer more resistance to thymol than any
other parasite except Oxyuris vermicular is, but this is probably
due only to the habitat of these parasites being so low down in
the bowel. The drug is, however, far from being inoperative,
so that it is common to find a dozen or more on the dejecta
after the customary dosing, but, as a rule, as many or more
will be left behind.
The prevention of infection, as indeed in the case of all
intestinal parasites, is necessarily entirely a matter of conser-
vancy. Moreover, certain observations I have made tend to
show that the life of this eiitozoon is but short, and hence such
measures alone will rapidly effect a cure by mere prevention of
re-infection. Three little monkeys that I obtained for experi-
mental purposes, five months ago, positively swarmed with
Trichocephali, but now, simply by being cleanly kept, scarce-
ly harbour any of them, and this can only be owing to the
death and expulsion of the majority of the parasites, combined
with the prevention of re-infection.
Ascuris lunibricoides is almost as common among the
Assamese as Trichocephalus, and not unfrequently exists in
such large numbers as by itself to constitute a distinct danger
to life. I have removed 45 large worms from the body of a
child a few years old, the whole mass weighing about
Jib, or nearly one-fiftieth of the weight of the host.
Although perhaps the commonest of all human para-
sites, we are in almost complete darkness as to its life
history, though direct infection by ova is surmised. The
large slightly elliptical ova have a very thick, nodulated
envelope of a bright yellow colour, the density of which
makes observation of the interior a difficult matter. When
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eposited, tliere is no sign of segmentation, and I have never
seen any change in such ova as I have kept under observa-
tion, but some accidental observations place me in exactly the
same position as I stand with regard to Triclwceplialus, as
lately, in some old cultivations, some peculiarly large rhabdites
have appeared entirely distinct from any stage of Dochmius
and from the possibly Tricliocephalus rhabdites.
This parasite, as is well known, often causes serious symp-
toms, and its extreme prevalence in Assam is no doubt one
of the causes of the low average of physical health of the
inhabitants.
In the treatment of patients for Ascarides, thymol has
proved itself infinitely more sure and effectual than santonine,
having often caused the expulsion of large numbers after santo-
nine had been tried and had failed to expel more than two
or three, so that, personally, I am unlikely ever to use santonine
again.
OxyuTis vermicularis is not uncommon in Assam, but
is proportionately much less so than the two preceding. The
ova are thin-shelled, unsymmetrically oval, and always contain
an advanced, lively embryo, which hatches out rapidly even
in water. Direct infection hy ova seems to be considered as
proved, alike by Leuckart and Cobbold, but a species, anatomic-
ally indistinguishable, which infest Macacus rhesus, certainly
goes throngli a distinct rhabditis free stage, and, though
prevention of direct self-infection was clearly impossible,
however cleanly the animals may be kept, they have, like the
Tricliocepkali become distinctly less^numerous during the period
the animals have been in captivity. Of course, however alike,
the human and simian parasites maybe specifically distinct, but
possibly both methods of infection are possible, and indeed the
circumstance that oxyurids are common enough in European
towns, where conservancy arrangements qua the propagation of
intestinal worms, may be considered as almost perfect, may be
alone considered sufficient to prove the possibility of self-infec-
tion. They are clinically unimportant in connection with
anchylostomiasis, and are less affected by thymol, adminis-
tered by the mouth, than any other parasite. A copious
enema of weak emulsion is, however, far more effectual in
expelling them than infusion of quassia, or any of the more
commonly used remedies.
Ampldstoma hominis, Lewis.—This curious little fluke
which, curiouslv enough was first found at Gauhati by Dr. J.
'
*'
O '
«/
O'Brien in 1857, and was described by the late Dr. T. E. Lewis
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in 1876* lias been repeatedly met with during the present
investigation, though not in numbers sufficient to constitute
a danger to the patient. Its habitat is the ccecum and colon,
and thymol appears to expel them with tolerable certainty.
A tailless cercaria, possibly of this species, was, on one
occasion, found in some mud used for plastering the walls near
a hut inhabited by a subject of this parasite. Lewis and
McOonnell found them by hundreds, in. which case they
would necessarily develop a clinical significance, but personally
I have never observed more than a dozen or so. I have
never met with the ova in the dejecta even in cases which
afterwards proved to harbour it, so that possibly these only
reach the exterior on the death and expulsion of the parent.
Distoma Crassum, Busk.—A single specimen of this
large fluke was expelled by thymol from a little girl at
Ohaygaon. Like many of her compatriots, this child har-
boured quite a museum of parasites in her own person, every
one of the species hitherto mentioned being represented. So
far as the scanty literature at my disposal enables me to
judge, this is the first occasion in which the occurrence of
this parasite in India has been recorded. In the case of a
missionary and his wife who had worked at Ningpo in China,
treated by Oobbold,f the most prominent symptoms were a
distressing diarrhoea, hepatic derangement, and wasting, but
very little is known about the species, and its habitat is only
surmised to be the hepatic ducts, and the only instance in
which it came under my observation being unexpected, and
complicated by the presence of so many other parasites, I am
unable to do more than to direct attention to its occasional
occurrence in Assam, and the possibility of its becoming the
cause of symptoms not altogether unlike those of anchy-
lostomiasis.
Cestode parasites.—Owing to the circumstance that the
people amongst whom most of my observations have been made,
never eat beef, and rarely consume pork, I have personally never
met with a case of tape-worm complicating anchylostomiasis,
but I am told by Dr. Hancock of Dibrugarh that he has
often met with, such cases among tea-garden coolies, and
I understand that these worms are very common amongst
the wild hill races on the south-eastern frontier of the Pro-
vince. The species would almost certainly be Tcenia
* Lewis McGonnell. Proc. Asiat. Soc. Bengal, August, 1876.
•j- Op. cit., page 22,
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tsolium., and, from what I can gather from others, thymol
would appear to be a far more efficient vermifuge in deal-
ing with them, than male fern or any of the other drugs
more commonly employed for the purpose.
Pediculi.—In the course of examinations of the dejecta
of patients affected with anchylostomiasis, I have repeat-
edly met with large numbers of immature pediculi crawling
about among the fseces. For a long time I believed their
occurrence to be purely accidental, and that they had
gained access to the stools after deposition; although in
some instances the rapidity of their appearance made this,
in the case of a wingless insect, extremely difficult of expla-
nation. Quite lately, while examining an unopened duodenum
preserved in spirit, I found six or eight of these insects
actually in the bowel, and there can now be no doubt
that the specimens met with in dejecta were deposited with
them, or, in other words, that the pediculi^ for some short
period of their lives, had actually been eutozoa. Now, this is
somewhat remarkable, as there is no previously known
instance of any non-larval insect acting in this way.
I sent down one of the most advanced specimens I could
find to Mr. J. Wood Mason, the Superintendent of the Indian
Museum; but, owing to its immaturity, he tells me that he
is unable to identify it with any known species.
I do not for a moment suppose that these insects pass any
length of time in the bowel, but, at the same time, believe that
they were born there. Any one who has watched the un-
sophisticated Assamese peasant when at his ease must have
noticed the habit they have of searching each other's heads for
vermin, and I have more than once seen the searcher deliberately
swallow the prey he had captured. Doubtless, the adult insect
gets crushed by the fingers and teeth; but the ova would
be unharmed, and, stimulated by the warmth of the
intestine, would hatch out rapidly. In no other way indeed
can the presence of these insects living, and in considerable
numbers, in fresh dejecta be accounted for, especially as all
are still immature when met with. Since making this dis-
covery, I have had no opportunity of investigating what
species of Pediculus infest the persons of Assamese villagers, so
that I am still in doubt as to what species these temporarily
entozoic insects should be referred.
They probably have no clinical significance, and I
merely here note their occurrence, because it is desirable to
put on record a fact which is, I believe, new to medicine.