NationalLibraryOfScotland/medical-history-of-british-india huggingface dataset:
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Intestinal Coccidia.—The frequency of the occurrence of
these organisms has already been noted on a previous page,
and needs no further notice here.
It must be confessed that the above is a formidable list,
and when the great frequency of many of them is remem-
bered, it cannot be doubted that amongst them they form most
efficient aids to the action of the afch-ofiender Dochmius
duodenalis.
Malarial Complications.—Complications of this character
are inevitable in any and every disease met with in such a
climate as Assam; but at the same time I believe that its
importance as a factor in the present increased mortality
has been enormously overrated.
A very good idea of the part it plays in an outbreak
of kdla azdr may be gathered from the tables given of the
relative prevalence of this complication in the case of Chunsali
tea-garden (vide page 143), but so much has already been said
on this subject in different parts of this report that its further
discussion here is unnecessary.
2 he Mode of Death in Anchylostomiasis.—Broadly speak-
ing, death in this disease always occurs from asthenia, but
the actual termination is usually brought about by the
supervention of some more or less acute complication.
Of these, perhaps the commonest of all is dysentery,
which seems occasionally determined by the action of
Irichocepliali.
The frequency of phthisis has already been noted by Leitz,
and several cases of the kind have come under my own
observation. More frequent than this, however, are subacute
broncho-pneumonia and bronchitis, which, acting on organs
ahead}?- almost incapacitated by oedema, are rarely entirely
absent, and rival bowel complaints in the frequency with
which they determine the fatal result.
The occurrence of other complications has been noted, but
they may be considered as rather accidental than as forming
a distinct feature of the clinical picture; the above compli-
cations being present either together or alone in by far the
larger proportion of cases, while death from the disease itself,
without determining complication, is certainly the rarest
incident of all. One such case, however, occurred in the
Gauhati dispensary, brief notes of which have already been
given, and here the patient died in the most typically
asthenic way it has been my lot to witness, the temperature
falling, and the lungs and heart hampered by dropsical
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effusions, acting more and more weakly, until the functions of
life came to a stop, much in the same way that a machine is
brought to a standstill by the dying out of the fire used to
originate its energy.
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X.—PREVENTIVE AND REMEDIAL MEASURES.
While this is undoubtedly the most important section
of this report, the conclusions to be drawn from the facts
recorded in previous sections, are so obvious that it appears
almost superfluous to record them. It has been shown that,
under different names, alike in native villages and among tea-
garden labourers, anchylostomiasis has for a long period
been causing a terrible mortality, and that nothing that has
as yet been done has had any effect in checking it. It has
further been shown that the disease is spread entirely by the
agency of the dejecta of the patients: that, apart from the
improvement of the condition of a few individuals, nothing can
be hoped for from medical treatment; and that the improve-
ment of even these few is unlikely to be permanent, as long as
the material of infection is allowed to lie broadcast over the
land. From these facts it follows absolutely that there is only
one possible way of dealing with the disease, and that is to no
longer allow the general fouling of inhabited sites, in other
words, to adopt ordinary measures of conservancy.*
It is perfectly clear that even under the horrible old
English cesspit system, the spread of this disease would be
a physical impossibility, and that even the most rudimentary
application of conservancy will go further to diminish the
disease than all other measures, sanitary and curative, put
together.
In the case of tea-gardens I can see no possible difficulty
in the matter, but in Assamese villages I am well aware that
the introduction of sanitation is beset with difficulties quite
apart from the question of expense, and hence I could wish
it were my lot to have to recommend measures easier of reali-
zation. This is, however, clearly impossible. To introduce
a good water-supply and drain village sites are 110 doubt
desirable, and would necessarily go far to improve general
health, but they can do nothing to check the spread of anchy-
lostomias, nor have they done so where attempted. Even sup-
posing drinking-water to be the common vehicle of infection,
and strong grounds have been given for believing it to be the
rarest of all, to attempt to keep it pure by masonry wells,
service tanks, and so on, while pollution of the soil around is
allowed to any extent, is obviously a circuitous and inefficient
plan of going to work, and leaves us much in the position of
* See paragraph 2 of Circiilar No. 14S., dated the 10th May 1889, and
also paragraph 3, Sanitary Commissioner's Circular No. IS., of 25th
March 1890.
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one wlio, wishing to prevent accidental poisoning, kept his water
in carefully corked bottles, while allowing arsenic to be strewed
about anywhere.
We are thus unfortunately placed under the dilemma of
either introducing conservancy, or of leaving the disease to
settle the question by depopulation. The introduction of
conservancy must necessarily be very incomplete at first, but
this should not prevent our at least attempting it, for, even
if imperfect, it cannot fail to do something to improve
existing conditions, for the burial of every single infected mass
is a distinct blow at the spread of the disease.
Such measures have been successfully introduced in other
parts of India, and though it is the fashion to speak of Assam
as an exceptionally backward province, it must be acknow-
ledged that many other parts of the country are not one
whit more advanced, and though the Assamese are perhaps
a shade more dirty in their habits than the average Indian,
the difference is too small to involve any great increase in the
difficulties of the problem, while, in general civilization, I fail
to see that they are at all behind'their neighbours, outside the
larger towns.
The question of village sanitation is cropping up all over
India; but, owing to the presence of this terrible disease, it is
nowhere so urgent as in Assam, and, save by its introduction,
I fail to see any hope for the amelioration of the disease. The
exact plan of operations and the methods of securing their
adoption are outside the province of the sanitarian, and
all that need be done here is to indicate what appear to be
the simplest and least expensive methods of conservancy,
assuming their adoption to be enforced.
There is one fact which has been discovered in the
course of the present investigation, which is of immense
practical importance in this connection, and that is that the
infective embryos can only live on the surface of the soil.
Bury them, and they are rapidly killed, and hence any simple
system of trench latrines will be quite sufficient for our
purpose. The great practical difficulty in the matter is the
scattered character of the Assamese villages, owing to which a
considerable number of small latrines will be required to meet
the convenience of the people; indeed, it is to be regretted
that we cannot adopt the system enforced by the Jewish
legislator (Deuteronomy, Chapter XXIII., verses 12-13), but,
this being impracticable, the number will have to be large in
proportion to the population, as, unless they be made a con-
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venience instead of a burden to the people, they are unlikely
to be used. In most places the expense of standing latrines
would be prohibitory, but simple trenches might be adopted,
into which a little earth should be daily thrown until the) 7
are nearly filled, when they should be closed and a fresh
trench dug. Standing latrines furnished with tarred gumlahs
and regular washing platforms would of course be better,
and might be adopted with advantage on tea-gardens and in
towns, but they would be too expensive for villages, and the
want of a sufficient population of the sweeper caste would
be an almost insuperable bar to their use, as regular removal
of the sewage to a trenching-ground is absolutely necessary.
There is nothing, however, in either digging a trench, or hoe-
ing a little earth into it, which need hurt any man's caste, and
the whole expense of such a system would be verj^ small.
No doubt, in the rainy season, the trenches would get full
of water, but this would be a matter of little moment, as the
ova and embryos would sink to the bottom, and they would
get buried just as surely, when the trench was filled in, as if it
were dry.
A proper dry-earth system would undoubtedly be far
superior, but, as the attainment of this is probably beyond
village finances, we must be content with such simple measures
as are within their means, remembering that, in dealing with
anchylostomiasiSj our one object should be to bury human
filth out of sight, and that any measure which will even confine
defilement to certain selected areas is better than nothing. In
large places, such as Barpeta, such a plan would be out of the
question. Eor such populations the adoption of proper dry-
earth latrines, with a proper conservancy staff, is the only
possible way of dealing with the matter ; but, in such places, the
expense would not be prohibitory, for the material prosperity
of the inhabitants of Assam is certainly greater than those, for
example, of the Central Provinces, and there, I know from
experience, that a very fairly efficient conservancy is carried
out by even small municipalities of only a few thousand
inhabitants. During my stay there, a return of inhabit-
ants capable of paying for medical attendance at the dis-
pensaries was called for, and the extremely small numbers
returned showed that the inhabitants were far from rich, so that
the expense cannot be prohibitory in places, for example, of
the size of Barpeta. In these towns in the Central Provinces
the latrines formed a circle round the town, but were placed
quite close to the houses. Each consisted of three buildings.
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One designed for the use of males, and divided up into separate
compartments, and another, of equal size, but not sub-divided,
for females. Eacli was provided with a well-tarred platform
for ablation, the drainings from which ran into a tarred recep-
tacle, and water was obtainable close by. The third building
was a shed for dry-earth. The buildings were constructed
either of galvanized iron or of ordinary country materials, and
the seats consisted of a couple of bricks, between which were
placed two small tarred earthen (jumlahs. In the male latrine
the partitions were of ordinary bamboo matting. Some of the
larger towns had proper conservancy carts, but, in the smaller
places, the filth was removed in small receptacles by hand.
The conservancy staff' was extremely small, so small,
indeed, that it was surprising that the latrines were as well
looked after as they were; it certainly did not exceed two men
for every thousand inhabitants, and the fact that the sweepers
somehow managed to do the work made me suspect that the
latrines could be but little used. That this was not the case,
however, I satisfied myself by personal observation. Some
of the larger towns badly required additional latrines in more
central situations ; and I have no doubt that much defilement
remained untouched, but the state of things was at least an
immense improvement 011 the conditions that must have existed
before their introduction, and nothing could show this better
than the comparative rareness of parasitic disease, on the
prevalence of which special returns were called for, the returns
from the various dispensaries showing that very few such cases
came under treatment.
An objection that is always raised to the adoption of
the dry-earth system in Assamese towns is the difficulty of
providing dry-earth. It is, however, purely imaginary. Assam,
if one of the dampest, is not the only rainy country in India;
and the difficulty is got over elsewhere by the simple method
of storing a sufficiency of earth during the dry weather to
last over the rains. In the part of the country I have just
alluded to, during three months, the rainfall is quite Assamese
in heaviness, but, though the sheds were very small, not 20
feet square, I should say, they contained a sufficiency of earth
to tide matters over the rainy period, and, in this country,
it can only be a question of increased accommodation, nor
need be of an expensive character. Eegular sheds are quite
needless, beyond a small service shed, which may be located
in a corner of the latrine, capable of holding a supply for a
few days. For the main supply, all that need be done is to
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throw up a heap or heaps of earth during the dry weather,
arraitging it, so as to form it into the shape of a roof. The
earth is then simply roughly thatched over with grass, and
from time to time a sufficiency to fill up the service-shed is
dug out from under the leeward end of the thatch. In this
wa}?-, at the cost of a few rupees only, it would be perfectly
easy to store an ample supply of earth to meet the exegeiicies
of even an Assamese rainy season'.
It is the duty of the sweepers to keep a little of the dry
earth dusted into each gumla, and, on emptying these into the
receptacles, to add a sufficiency to deodorize the mass. Once
a day, the receptacles are removed, either in a cart or by hand,
to the trenching ground, which should preferably be situated at
a little distance from the town, but not at a sufficiently great
one, to form a temptation to the conservancy men to shirk their
work by emptying them into any hidden corner. In the
absence of constant European supervision, this is a matter
which is often not sufficiently taken into consideration. In view
of the special dangers of anchylostomiasis, I should be inclined
to recommend the use of deeper trenches than are usually consi-
dered desirable, say, 24 feet, and giving a full eighteen inches of
clean earth on top of the soil, so as to bury all infective material
thoroughly and deeply. Waste land should never be chosen for
this purpose, as, after being used for trenching during one season,
it is essential that the ground should be cropped ; otherwise, in
the course of time, it will lose its deodorizing powers. I have
heard that an enormous yield of sugarcane can be got from land
that has been so treated, but my own experience has been
limited to corn lands, and, in one instance, to lucerne-grass,
the yield of which was something astonishing. The drier the
piece of ground chosen for the purpose, the better, but I do not
look upon the trenches getting filled with water as an insuper-
able objection. The result will of course be not as good as
in more favourable climates, but the essential point is to bury
the infective matter, where it cannot be carried back into the
houses; and, where the best is unobtainable, we must be
content with the nearest approach to it we can get.
Disinfection of Sites already injected.—Having thus indi-
cated the way in which the future spread of the disease may
be surely prevented, it remains to be considered how sites,
already infected, should be dealt with.
Provided only that all further supplies of nutritive matter
be cut off by efficient measures of conservancy, it may be con-
sidered certain that, sooner or later, the infective embryos
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must die out, but unfortunately, we know that the time required
for this may be very considerable.
It certainly exceeds six months, even in the absence of
fresh nutritive supplies, and may be much longer. Given the
continual supply of fresh nutriment, inevitable, where no
attempt is made at conservancy, the infection of a site may
last for an indefinite time, and indeed, is more likely to increase
than decrease.
Two principal plans suggest themselves, the first of
which has been found to be tolerably efficacious by the people
themselves, viz., desertion of the infected locality. Now, pro-
vided that the elimination of all infected persons could be
secured by efficient medical inspection, this plan would be
absolutely effectual even in the absence of all conservancy at
the new site. Unfortunately, however, such a course is quite
out of the question in actual practice, and hence migration only
checks, and cannot stop, the spread of the disease, unless the
inevitable infection of the soil of the new site be prevented
by a proper conservancy. Without this, unless the people
were to become absolute nomads, moving every week or so,
migration can only be a palliative measure.
Given, however, the avoidance of foaling the soil of the
new site, migration from infected localities may be strongly
recommended wherever practicable.
The natural habits of the Garos lend themselves easily
to this plan of action, and, as the introduction of sanitary
measures will be peculiarly difficult among such a wild race,
they should be encouraged in this custom as far as possible. In
the case of tea-gardens, the alteration of the site of the lines can
often be carried out, and should be effected wherever practicable,
of course coincideiitly with the introduction of proper measures
of conservancy on the new site.
The disinfection, of already-infected sites is doubtless a
much more difficult matter, but cannot be regarded as hope-
less. On account of the broadcast way in which the infective
embn r os are spread about such localities, and the impossi-
bility often of recognizing the places where they are to be
found, either by sight or smell, the use of all chemical disin-
fectants is clearly out of the question, but there are three
facts (which appear in Section VIII.) of which advantage may
be taken ; and these are—
1st.—Prolonged exposure to the direct rays of the sun
kills the embryos.
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2nd.—The same result may be effected by exposing
them to a temperature exceeding 140°F.
3rd.—Burying the embryos kills them.
In order to take advantage of the first fact, all that is
required is to clear the ground of vegetation as thoroughly
as possible, at the commencement of the dry weather. The
second property may be taken advantage of by firing the dry
vegetation at the end of that season. For, as the embryos
are confined absolutely to the extreme surface layer or the
soil, the passage of a grass fire would certainly kill smy that
might have survived the dessication of the dry season. Lastly,
by ploughing the ground at the commencement of the wet
season, and so turning the surface layer under and burying
the contained embryos, we may complete the disinfection,
more especially of such parts of the sites as, for any reason, could
not be treated either by clearing or by fire. This last expedient
is, of course, available at any time of the year when the soil
is soft enough for the process.
I feel assured that, by attention to these points, the disin-
fection of sites may be secured, though I necessarily have not
been able to test them in actual practice.
Purification of water-supply.—It is a fortunate circum-
stance that the physical properties of the embryos are such as
to render infection by drinking-water an unlikely contingency.
They sink so rapidly in water, that, a short time after the in-
troduction of even a large number into a well, all of them
would become entangled on the mud at the bottom, and
infection could only occur by the scooping up a portion of the
sediment.
At the same time, more especially for the protection of
officers travelling in affected districts, it may be well to point
out that filtration affords an absolute security against infection
by this agency. Any of the ordinary filters in common use are
amply adequate for the purpose, as, owing to the, microscopi-
cally speaking, large size of the infective embryos, even the
c oarsest filters will exclude all chance of infection. In illus-
tration of this may be instanced an experiment which I made,
to ascertain how far an ordinary handkerchief would serve as
a filter.
A piece of nainsook was placed over a glass funnel, and in
the bag so formed was placed a quantity of earth which literally
swarmed with embryoes. Water was then allowed to run
through for a considerable time, and the filtrate collected. It
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was of course extremely turbid and obviously unfit for drink-
ing purposes, but the most careful examination revealed only
two embryos in the filtrate, while the residue on the nainsook
was proportionately richer in them than ever.
With respect to attempts directed to the relief of the
sufferers from the disease in Assamese villages by medical
treatment, I have already plainly expressed my opinion. The
attitude of the peasantry towards European medical treatment
is such that it is perfectly certain that none but advanced
cases will be persuaded to submit themselves to treatment.
Such cases are practically incurable, and hence it is perfectly
certain that the good effected by itinerant medical subordi T
nates, extra dispensaries, and medical agencies in general, will
be so minute that, for all practical purposes, any money so
expended will be no better than wasted.
As an adjunct to proper sanitation, such measures can do
no harm, and may even effect some small good; but, unless
proper measures of conservancy be adopted, the re-infection
of the few cases cured will be so inevitable that nothing but
discredit to the cause of European medicine can result.
In the case of the tea-gardens the case is quite different.
The labourers, to begin with, come, for the most part from
districts where the people have been long accustomed to the
benefits of European medical treatment, and generally
thoroughly appreciate it. Further, they are a great deal more
under control, and can be dealt with, as far as sickness is
concerned, almost in the same way as the men of a regiment,
and, indeed the reception of all sick in regular hospitals is
a well established custom.
With very few exceptions, however, treatment is carried
out under the very mistaken policy of waiting till the man reports
himself as sick, before attempting treatment. In the case of
nine diseases out of ten, this is undoubtedly the best plan
to adopt, but in that of anchylostomiasis ii too often leads
to the postponement of treatment until the man is beyond cure,
and, at best, necessitates prolonged treatment and disability for
work in place of two or three days' stay in hospital only. On
this account,* I cannot too strongly urge the adoption of
systematic periodical medical inspections of all labourers em-
ployed upon tea-estates, combined with the prompt treatment of
all cases that may be detected, in addition to which, it is need-
less to say that all newly-arrived hands should be inspected,
* See paragraph 49, Annual Sanitary Eeport for Assam, 1888.