NationalLibraryOfScotland/medical-history-of-british-india huggingface dataset:
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becomes little better tlian a large cultivation ground for the em-
bryos, and, in such situations, there is never any difficulty in
finding abundance of them. Assam is essentially a muddy
climate : even in the cold weather, the daily morning fogs keep
the surface of the soil continually moist, and, when it is much
trodden upon more or less muddy, and it is only during the short
dry season that the surface becomes absolutely dry, and, even
then, the soil will be found to be damp at a very little depth.
Hence, in entering his hut, and in moving about amongst his
neighbours, the inhabitant of an infected village must always be
getting his feet covered with mud, which is absolutely teeming
with infective embryos. When we remember that a bit of
mud no larger than a pea may contain score's of them, it
is easy to see what multitudes must be introduced into the
house each time the occupants enter it. Once within the house,
there are many ways in which the embryos may gain access to
the intestinal canal of the inhabitants. For example, food is
always eaten squatting on the ground, with, at most, a bit of
seldom-cleaned matting as at once table and table-cloth.
Under such circumstances cleanly eating is impossible, and a
certain amount of the dirt of the floor is pretty certain to get
into the dish at each meal. Not only so, but, in the position
natives sit when eating, their hands necessarily often come into
contact with their feet, and, as they have no other forks than
their fingers, these latter must often convey into their months
dirt from their feet or the floor. Again, in course of time, the
infected mud, which must necessarily be introduced into the
house, will become house-dust. Now the very moderately in-
tense drying that would take place in such a house, would be
quite insufficient to kill the embryos, and being, when dry,
very light, they must be raised into the air with the other
constituents of the house-dust, and descend on food and upon
cooking utensils, and it is quite possible that some may be
drawn into the nasal passages in respiration, and so gain access
to the stomach together with the nasal mucous, which is con-
stantly flowing, through the posterior nares, into the pharynx.
There are other native habits which also greatly favour infec-
tion. One of these is that of cleaning brass eating utensils with
earth taken up anywhere, and I have actually seen a woman
cleaning her platters with earth which I ascertained to be in-
fected, and, as an instance of their utter callousness to the most
ordinary considerations of niceness, I may mention that in this
very instance I saw her husband calmly easing himself, on the
same patch of ground not many yards off. Another habit
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favouring infection is that of smearing the walls and floors with
mud mixed with cowdung, in the preparation of which compost
infected earth is often used. In its application no other trowels
than the hands are used, and the users are, we may be sure.
none too nice in cleansing them before employing them to
handle their food. In fact, the habits of the Assamese could
not better favour infection had they been specially devised with
a view to the purpose, and the only wonder is, not that so many
are infected, but that any escape. Nor are such habits con-
fined to the poor and wretched; in fact the advantages
enjoyed by the educated clerk in an English office consist
more in better clothing and food than in any essential
difference in the sanitary tendencies of his domestic habits, so
that they in no way share the immunity from attack that is
enjoyed by Europeans. The longer the disease remains in a
village, the wider will the area of ground become, the
surface of which will teem with thousands of infective
embryos.
As far as my experiments on this point go, they tend to show
that the embryos do not spread very widely around the centre on
which the ova were deposited. They are too much entangled in
the surface mud to be spread very widely by ordinary rain. Still,
in time of flood, especially where there exists a current of any
strength, the embryos must often be carried to considerable
distances, and, wherever they are deposited, they will lie in the
resting stage for months, only awaiting the accidental deposit
of a fresh supply of fsecal matter to breed and multiply, and
start a fresh centre of infection. In this way, large portions
of the area of Jcdla-azdr villages may come into such a state
that the accidental introduction of a small portion of the
surface soil into the intestinal canal will be sufficient to produce
the disease in a new host. Unobservant as the peasantry are,
they have at least recognized the persistent way in which the
disease clings to any place in which it has once established itself,
and know well that no measure of prevention is so effectual
as the entire abandonment of such sites.
From what has already been said, it will be seen that, as
a rule, infection must be a very gradual matter. Cases may,
and no doubt do, occur in which the accidental swallowing of a
large dose of infective matter may suffice to introduce a number
of embryos large enough to cause serious mischief, and, indeed,
some cases of an acute character can hardly be accounted for
in any other way; but usually the process must be a very gradual
one, and far from being a matter of a single infection, the process
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more probably is a matter of almost daily small increases from
the beginning to the end of the case, during which I am inclined
to believe that often several successive sets of parasites may
come and go before the fatal termination. It is owing to this,
that treatment out of hospital is such a discouraging, and
indeed hopeless, matter, for, owing to the necessarily constant
recurrence of infection, only a temporary improvement can be
expected. The ground round the hut that has been occupied
by a case of anchylostomiasis must soon get in so highly
infective a condition that, if the patient is to return to it,
treatment can be little better than a waste of drugs.
Probably in no two cases is the rate of infection uniform
or similar, and the spread from man to man in a village must
necessarily be equally irregular and uncertain for the indivi-
dual, though inevitable for a considerable proportion of a
village population. The rate and method of spread are in
fact just what we find in Mla-azdr, and are necessarily
entirely different from the phenomena to be observed in
directly infective diseases, such as the specific fevers. In
anchylostomiasis, the infection is indirect, and mere contact and
association with a patient are quite incompetent to transmit the
disease, whereas, in ordinary communicable diseases the infec-
tion is direct, and there is usually no difficulty in tracing its
source. It was undoubtedly with the phenomena of direct
contagia, such as these, alone in their minds, that previous
observers of Mla-azdr have so confidently stated that there is
no evidence in favour of its contagiousness, and, so limited,
their deduction was perfectly correct. In reality, however,
anchylostomiasis, for people in a low grade of civilization, is
one of the most infectious of all maladies, taking the word in
its broad sense of communicability, and the method of its
spread coincides exactly with the facts observed in connection
with the spread of kdla-azdr.
On the other hand, the danger of infection is almost nil
for Europeans, even in India. The mere fact of eating at a
table, with knives and forks instead of fingers, is alone almost
sufficient to secure immunity, and in even the most backward
European towns, the system of conservancy, however badly it
might be conducted, would suffice, to prevent all chance of con-
tracting the disease. Were the whole of the affected popula-
tion in Assam suddenly transferred to London to-morrow, not
a single case of infection could possibly occur, as long as the
new-comers were forced to live under the same conditions as
Londoners.
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There is, however, one danger of infection for Europeans
in India, about which a word of warning may not be out of
place. I refer to milk supply. In Gauhati, for example, the
danger is a very real one. The greater part of the milk consumed
by the residents is brought into the town from Paru, and other
villages, where kdla-azdr is rife. It is conveyed in galvanized
iron buckets, and any morning the milkmen may be met coming
in, each with a couple of buckets slung on the ends of a bamboo.
To prevent the milk splashing and being lost, they place in each
bucket a wisp of reeds or grass. Now, it is perfectly obvious
that the reeds may have been taken from a bhil swarming with
embryos, and it is even more likely that the udders of the cows,
and the hands of the milkers may be fouled with mud so infected,
and though I have met with no case where any suspicion of infec-
tion of a European has occurred, it behoves all residents of such
neighbourhoods to be careful that all milk used in their houses
is thoroughly boiled,—a precaution which will certainly render
safe any specimen of milk, however badly it might be infected.
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IX.—BEMARKS ON THE PATHOLOGY, DIAGNOSIS, AND
TREATMENT, &c., OF ANCHYLOSTOMIASIS.
To attempt any exhaustive treatment of this subject
would involve writing a treatise of nearly the bulk of the
entire present report. Moreover, the task has already been
too well accomplished to make it either necessary or desirable
that I should do so, and all that is here attempted is to
emphasize some old points that appear of special importance,
and to notice a few new ones that have cropped up during the
present investigation.
The importance of an early diagnosis in cases of anclry-
lostomiasis cannot be overrated. If we wait till matters are
gone far enough for the patient to be unfit for work, the
chances are that the time has passed during which he might
have been saved. When first it was discovered that kdla-
azdr was actually anchylostomiasis, but having no previous
practical experience in treating the disease, I naturally hoped
that the expulsion of the parasites would be sufficient to
initiate a cure, and the rest would be merely a matter of
waiting until a sufficiency of food had been assimilated to
make up for what had been lost. This a priori notion would
doubtless have proved correct enough had the patients retained
the power of assimilation; but a further experience of the
disease has demonstrated the fact that the mere loss of nutri-
tive matter required for the support of the parasites is a
small and quite unimportant factor in the causation of the fatal
symptoms produced by them. Various calculations have been
made as to the amount of blood actually withdrawn by the
parasites, and these, though differing pretty widely, agree in
making the amount too small to be likely to do more than
seriously weaken an adult. The real damage is mainly caused
by the destruction of the digestive powers. A large share in
the causation of this diminished power of assimilation, is proba-
bly to be accounted for by the constant recurrence of great
numbers of small traumatic lesions of the mucous mem-
brane. Should these lesions include boring, and temporary
encystment, the matter is the more easily understood ; but the
bites themselves, in spite of their small area, can account for
much.
Microscopical examination has shown me that the gnawing
of the parasite produces an erosion which extends to the sub-
mucosa. Now, we know that, once damage of an epi or endo-
thelial surface has gone to this extent, repair takes place by
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the formation of a scar, and not by reproduction of either true
skin or secreting mucous membrane, so that each bite must
leave a small area incapable of ever again performing its
natural functions. The number of bites always largely exceeds
that of the parasites, so that each probably inflicts several
small injuries in the day, and when this is multiplied by a large
number of parasites, acting through a long period, the total
area so affected may become very considerable, especially as
the duodenum and upper part of the jejunum are one of the
most important portions of the intestinal tract. Again, in the
examination of advanced cases, the stomach is always seriously
affected; it usually shows scattered petechise and a peculiar
mammilated, leathery appearance of a dull slatey red hue, which
is most often best marked along the greater curvature, and
which reminds one, more than anything else, of the grained
appearance of morocco leather. It is undoubtedly this change
which is referred to in Mr. McNaught's accounts of post-
mortem examinations of kdla-azdr cases. This mammilated
appearance is so peculiar that, on first seeing it, I was con-
vinced that it must be due to small cysts in the mucous mem-
brane, and that the encysted parasite would readily be found
in them. Careful microscopical examination, however, failed
to show any sign of the parasite, but only an elevation of the
mucous membrane caused by inflammatory infiltration of the
submucous tissue, and often enclosing a small old blood clot.
It is very possible, however, that they may be the remains of
cysts, which once contained parasites, which have escaped in
the due course of their development. Their close resemblance
to the changes found in the stomachs of equine animals affected
with Sclerostomum teracanthun, where there is no doubt about
encystment, strongly supports this view.
The ultimate result is a chronic gastritis, with thickening
over certain portions of the mucous membrane and atrophic
changes elsewhere; the very process of repair leading ulti-
mately to wasting and functional uselessness of the organ. The
changes in the intestine are very similar, though large thickened
areas are rarely met with. The principal organs of digestion
having been reduced to this condition, proper assimilation
becomes impossible, and a condition of slow starvation follows,
under which the losses of blood, small in themselves, rapidly
produce the perniciously anaemic condition with which we
are so familiar.
Apart from this, it is well known that starvation, or any
condition equivalent to it, may, in itself produce, changes in the
i
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assimilative mucosa, which, though difficult of exact anatomical
definition, are none the less quite fatal to the function of these
organs. The most prominent symptom of this is usually a
looseness of the bowels, the well-known " famine diarrhoea," so
often noticed in reports referring to the great Madras famine,
though constipation or an alternation of these conditions were
sometimes met with. In such cases, recovery was practically
unknown, and that in spite of the most careful feeding, which
the digestive organs having almost lost their assimilative
O
o
O
powers, had become practically useless. Now, the condition
into which patients are brought by anchylostomiasis closely
resembles that of starvation, and no one can look at old pho-
tographs of the victims of the famine, without being struck
with the fact that a similar series taken from a kdla-azdr
village would be quite indistinguishable by the closest scrutiny.
Moreover, the symptoms of the fatal dyspepsia are closely
similar in both, though modified by the circumstance that, in
anchylostomiasis, the bowel, in place of being empty, habitually
contains plenty of food. It is probably owing to this that
constipation is a much commoner symptom in the disease we
are considering than in the dyspepsia of famine, the watery
flow being mechanically stopped by the mass of undigested
matter encumbering the lower bowel, until re-absorbed, and
which it lias not the strength to expel. In spite of this,
attacks of diarrhoea of long duration are an almost constant
symptom of anchylostomiasis, but usually these attacks alter-
nate with shorter periods of constipation.
I am anxious to give great prominence to the primary
importance of dyspepsia in the production of the cachexia
of anchylostomiasis, because I meet with many who, from
failure to appreciate this fact, attach an undue importance to
the failure of thymol to effect a cure in advanced cases, argu-
ing that, because the expulsion of the parasites fails to cure
the disease, they are therefore not its cause, and that there must
have been some antecedent cause at work, whereby the patient's
economy is rendered a suitable home for the parasite. Now,
this is an argument that, at one time or another, has been raised,
and abandoned in the case of every parasite that troubles the
human body, and its mere production argues an entire igno-
rance of the broad general laws of parasitism. The healthier
the host the better he serves the purpose of his unwelcome
guest, and any falling off in his health must necessarily be pre-
judicial to the welfare of the parasite, as, if the loss of health
be progressive, the ultimate result must be its destruction. In
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connection with this Cobbold* remarks—" Most people, not ex-
cluding even the votaries of the healing art, following tradition,
regard the internal parasites or eiitozoa as creatures either
directly resulting from certain diseased conditions of their hosts,
or as organisms which would not have existed if their bearers
has been perfectly healthy. Nothing can be more absurd.
Such a conclusion is utterly at variance with all logical deduction
from known facts. It is, however, quite on a par with multi-
tudes of other popular delusions, which, in spite of the advance of
science, will probably never become wholly eradicated from the
public mind. People who hold these notions cannot or do not
desire to reject a view, which has for them a dominating-power
almost equal to that of any known religious dogma." Yet these
same people, who would at once recognize the absurdity of insist-
ing on the necessity of a predisposition, to permit of the action of
the deprivation of food, in the production of starvation, still
would assume such a necessity to account for what is prac-
tically the same state when brought about by the action of
parasites. The fact is that fallacies of this description die hard.
Dr. Kynseyf* divides the symptoms of anchylostomiasis into
3 stages,—(1) the dyspeptic; (2) the ansemic ; (3) the dropsical—
and though the arbitrary division of the gradual processes
of disease into distinct stages is rather to be deprecated, his
classification recognizes the truth of the primary importance of
the dyspepsia, and the manner in which it actually underlies
the ansemia. Its disadvantage is that it does not sufficiently
emphasize the fact that dyspepsia, besides being the earliest
symptom, is continuous throughout the case, that, far from
diminishing when the aneemic stage is reached, it increases
in severity with the progress of the case, from first to last, and
that it is largely the cause of the aiiEemia, and not entirely
its elfect, though the actual loss of blood caused by the
depredations of the worms has also an important share in
the resulting bloodlessness. Practically speaking, however, we
rarely, if ever, get the opportunity of recognizing the disease
previously to the supervention of anaemia, at any rate in
Assam, where cases will, as a rule, run into the dropsical stage
before they apply for medical assistance, and rarely indeed
seem to consider themselves as ill, until matters are very far
advanced. When once the anaemia has declared itself, how-
ever, the diagnosis, after a little practice, becomes very easy*
* "Parasites: a Treatise on the Entozoa of Man and Animals." By
T. Spencer Cobbold, M.I>. } F.E.C s. J. & A. Ghurcliill, London, 1879, page 1.
t Op. Oil., page 5.
i2
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The peculiar character of this anaemia and the way in which
it may be distinguished from other cachexias have already been
described on a previous page, and so need not be repeated
here. Even laymen soon become expert in recognizing the
condition, and I was much struck with the way in which a
gentleman managing a tea-garden in the Lakhimpur district,
while walking over his estate, picked out early cases at a
glance, and at once sent them off to hospital for treatment.
The coolies, I -may remark, seemed in no way to resent being
treated in this way, and the undoubted success that has
attended this gentleman's attempts to cope with the disease,
serves as a ready answer to the objection that always meets
one- when systematic medical inspection and treatment of early
cases is proposed. Nearly always the reply is that the coolies
would not submit to such treatment, and would desert if one
attempted to deal with the disease in this way ; but here, as
in the case of conservancy, the objection is purely a priori,
and the objectors have never troubled themselves to test the
soundness of their theory by giving the system a practical trial.
But, even supposing the objection a real one, though I doubt
if it has the least foundation in fact, it would be surely better
to risk the chance of the loss of the services of a few men by
desertion, than to face the certainty of the entire loss of a large
number of men by death, and the diminution of working
power of perhaps half the remainder. In the instance, however,
which I have mentioned, I was assured that the popularity of
the garden had in no way suffered, and that, on the contrary,
the coolies seemed rather to appreciate the care taken of them.
Once the ansemic stage is fairly entered, there is no diffi-
culty in making a diagnosis, which is certain enough for all
practical purposes, but in very early cases some doubt may be
felt, and in such cases, before submitting the patient to the
ordeal of treatment with thymol, it is always well for the me-
dical attendant to make sure of his diagnosis by microscopical
examination of the dejecta. The examination is a very easy
one, and requires neither the use of high magnification, nor
anything more than a most rudimentary acquaintance with
microscopy. The easiest plan is to dip the end of a strip of
bamboo into the specimen to be examined, and with it to
smear a minute quantity on an ordinary glass slide. A drop
of water is then placed on the smear and a thin cover applied.
By gently moving the cover to and fro on the slide, the water
and the material for examination become intimately mixed
together, and the slide is then placed on the stage of the