Ancylostoma duodenale and the Saint Gothard anaemia Size：1.95 M | View：18 | Page：41942 BRITISH MEDICAL JOURNAL VOLUME 287 24-31 DECEMBER 1983DifficultyearsThe next few years were difficult ones, with many changes ofstaffand disagreementsabout policy and management. Overallhung the constant criticism that the Family Doctor publicationsgroup was failing to earn its keep.The ...
1942 BRITISH MEDICAL JOURNAL VOLUME 287 24-31 DECEMBER 1983DifficultyearsThe next few years were difficult ones, with many changes ofstaffand disagreementsabout policy and management. Overallhung the constant criticism that the Family Doctor publicationsgroup was failing to earn its keep.The lowest level was reached in 1971 and closure seemedimminent. Itwas atthis pointthatmycolleagueKenGoldsmithand I approached the Family Doctor committee and askedto beallowed the chance to take over, and webecame business mana-ger and executive editor, respectively, in 1972. Each year sincethen has seen an improvement in our position. We increasedour publishing activities, paid off fully the outstanding debts,including the launching costs of Family Doctor magazine, andnow exist on our own earnings, at no cost to the BMA.I am glad that we have hadnomajorproblems andnopublicrowsinthesepast 12years. Iamnotacombative personality andprefer to get quietly on with the job inhand-givingthe publicsoundinformationandadvice onhealthmatters, andpersuadingand helping doctors first to write it, and then in many cases torewrite it for them, to make it suitable for lay readers.The biggest crisis I had to face was in 1978. I had accom-panied the chairman of council (Sir James Cameron) and thesecretaryoftheassociation (DrElstonGrey-Turner) toParisforthe launch there of a French version of You and Your Baby.It was a grand occasion and we were honoured by the presenceof Madame Simone Weil, at that time the French Minister ofHealth, at our reception, and all the top officials ofthe FrenchMedicalAssociation. TheBMApartydecidedtostayoninParisovertheweekend,butIflewbackearlyonSaturdaymorningasIhadtickets thateveningfor GotterdammerungatCovent Garden.(Things dont change much, do they?) On Sunday evening Iwatched the television news showing a warehouse at St Pancrasstillburningafterthebiggestfiresincetheblitz.Gotterdammerungindeed-for itwastheFamily Doctorwarehouse, noless,andwelosteverysinglepublicationwepossessed,andmostofourrecords.Phoenix-like we rose from the flames and we were back inbusinessintwomonthswitheverythingwewishedtokeepgoingrevised, reprinted, and replaced within a year, thanks to thesplendid cooperationofourprinters, andallout efforts fromthestaff.Earlier this year I had lunch with my old friend Dr DorisOdlum, president of the Samaritans and at the age of 93 stillgoing strong. I told her that I had been advised to take earlyretirement as soon as possible. "How long have you been atFamily Doctor?" She asked. "Twenty seven years." I said."Well Brownie, dont have any regrets, youve had a very goodinnings." Dear Doris. I rest your case.Ancylostoma duodenaleandthe Saint GothardanaemiaRPEDUZZI, JCPIFFARETTIThis year sees the celebration of the centenary of the officialopening of the Saint Gothard railway tunnel, and we felt thatit would be ofinterest to recall the epidemic ofancylostomiasisto which so many ofthe workmen fell victim. This problem ofhygiene rightly had wide scientific and political repercussionsat the time, as well as echoes among the public. The anaemia,which first appearedin 1880 whenthe tunnelwas being bored,led to major advances in parasitology, by way of research intothe aetiology, epidemiology, and treatment of ancylostomiasis.Eventothisday,thisinfestation,whichhasclaimedinnumerablevictims in tunnels and mines, is still a serious medical andsocial problem in several tropical countries.BackgroundAtthe beginningof 1880 a largenumber ofworkmen, mostlyfromPiedmont,returnedhomebecausetheyhadsevereanaemia,which had rendered them unable to work. Nevertheless, theircondition did not improve but became worse, and severalworkers died. In February 1880 an Italian workman who hadbeen employed in boring the Saint Gothard tunnel died of"pernicious anaemia" inhospital inTurin. DuringthenecropsyProfessor Perroncito found no fewer than 1500 ancylostomas inthe duodenum and jejunum.2 Less than a year later togetherIstituto Cantonale Batteriosierologico, 6904 Lugano, SwitzerlandRAFFAELE PEDUZZI, PHD, director, lecturer at the University ofGeneva, SwitzerlandJEAN CLAUDE PIFFARETTI, PHD, associate director, lecturer at theUniversity ofGeneva, Switzerlandwith Concato he reported, first to the Academy ofMedicine atTurin3 and then to the Academy of Sciences in Paris,4 threefurther cases ofworkers on the Saint Gothard tunnel sufferingfrom severe anaemia in whose faeces numerous ancylostomaova had been found. The three workers stated that hundredsof their workmates at the tunnel workings had had symptomssimilar to their own for a long time.Two Turin doctors, Bozzolo and Pagliani, then went toAirolo and confirmed the presence ofparasite ova in the faecesof numbers of workmen working in the tunnel. Nevertheless,they had strong reservations about the aetiological associationbetween this parasitic infestation and what they called an"epidemic pernicious olighaemia," a disease which, as DrCaglioni said about Airolo, resulted in "meeting these sadyellow faces everywhere in the streets of Airolo, faces whichwere upsetting to see."5 The roots of the disease, the twodoctors thought, were rather to be found in the deplorableconditions of general hygiene, both in the workers privatelives and attheirplace ofwork. Thealarm aboutthemysteriousSaint Gothard disease was sounded by certain Italian news-papers, with considerable repercussions on public opinion.Motions were submitted to the Italian parliament, which founditself faced with the serious political problem of guaranteeingacceptablelivingconditions forthethousands ofItalianworkersemployed on the Saint Gothard tunnel.The controversyOn 18 March 1880 the Federal Council commissioned DrSonderegger to carry out an investigation. After visiting thesite, he at first concluded that the Saint Gothard disease wasnothingotherthan a form ofthe well known "miners disease,"BRITISH MEDICAL JOURNAL VOLUME 287 24-31 DECEMBER 1983which was also called "mountain cachexia"-a disease which ?3-1for decades had affected coal miners working in a number ofpitsin Belgium and France and which had also occurred inmines of different types in Germany, Hungary, and Italy. He -later had to revise this opinion.6 7 It is illuminating to see just _how Dr Sonderegger began his report on the investigation hehad been instructed to carry out by the federal government:"Minersanaemiaorankylostoma?" That was howthequestionwas put. It was thought at that time that miners anaemia wasdue to intoxication from contact with or inhalation ofunknownsubstances present in the air in the mines. In response, Pro-fessor Perroncito obtained stools from workmen with typicalsymptoms of Saint Gothard disease, but who were working ina mineinGermany,and demonstrated thepresence inthestoolsof numerous ancylostoma ova. The arguments between the2E .......++ -----------which it entered the body. This gap in knowledge was fully4+.+.-,..... ::.......................................g ..........:}:!awax loited by the opponents of the theory of the parasitict... provided..p..aetiology ofthis disease.~~~~~~~~~~~~~~~~~~A........In fact, to the claim by Bozzolo and Paglianis that "theimpurity ofthe water used for drinking in the galleries hascontributedto the spread of the ova of the ankylostomum"Lombard_could reply, "These gentlemen are evidently un-aware that the employers ofthe tunnel workers have for some... ~ yars provided a supply ofdrinking water which leaves nothingto be desired. . . . The water is obtained from the Tremolaand is ledthroughmetalpipesbeginning 1800 metres above thetunnel. The water thus reaches the lower parts of the tunnelwithout having had any contact with the tunnel itself. It comesfrom Lake Sella, above the hospice, and runs over a granitebed so that it is the purest water in the Airolo region. Further-sciencmore, it is worthwhile adding that the Italian worker in generalis very careful in the choice ofwater he drinks, and that he iscareful to avoid drinkingwater which, ottenmuddy, runs at his~. feet."What was not known was that the workers became infectedpreciselyto the level at which their legs were immersed in thiswater, as may be confirmed by examining the life cycle of theon the subjeets this parasite as it is known today. Lombard tried to refute the workof Concato and Perroncito by countering them with the ob-servations made by the doctors ofthe Saint Gothard company,stated Dr Giaccone for the Airolo site and Dr Fodere for the-%A -;( .-~ Goescheenn site. These doctors, however, did not possess thenecessary diagnostic equipment to see the ova of the parasitesin the stools. Lomboard himself admitted this lacuna in theproponents and adversaries of the parasitic origin of SaintGothard disease becamemore and more bitter, even duringscientificandpoliticalmeetingsatthehighestlevel. DrLombardwrote in the Archives des Sciences Physiques et Naturelles deGendve as follows: ...the presence ofankylostoma as a causeofthe disease sufferedbythe tunnelworkers, is purehypothesis... in spite ofthe assertions of some people who have writtenon the subjects this parasite has not been observed by thedoctors treating the patients," and in concluding his article,stated "The facts have been conscientiously studied and aresufficientlyclear to confound what I will call the legend ofankylostomiasisand the legend of the ubiquiti of Saint-Gothardtunnelanaemia" (ouritalics).8An important factor for understanding the reasons for thecontroversy is that, though there was ample knowledge aboutthe biological cycle, embryology, and development of theparasite,there was complete ignorance about the means by1943THE (IMILLTION OF IIIL Sl. GOTHARD IUN.%LL, ILU. .9, .88-THE NILETING OF TIIE NNORK."ILN1944investigations, when he said of Dr Giaccone, "Not having amicroscope, he could not look for ova in the faeces." In themeantime numerous cases of anaemia among the workers atthe Goeschenen site began to be reported.Clinical findings and treatmentThe doctors who were most active in helping these patientsandwho, thanks to their investigations, also solved the problemof the treatment of Saint Gothard disease, were Edoardo Per-roncito at Turin9 " and Ernesto Parona at Varese, both ofwhom cared for large numbers of Gothard workers."1 12 To-gether with his clinical research, Perroncito also studied thebiological cycleof Ancylostoma, culturing them from ova ob-tained from his patients and obtaining two larval stages. Hestudied the effects of the most widely different-physical andchemical treatments on the larvae, until he finally obtained hisfirst therapeutic successes with high doses of ethereal extractsof male fern. The disappearance of ova in the stools corres-ponded with a definite and progressive improvement in thepatients general condition, with restoration to full healthaftera few months.Necropsiesonpatientswhohaddieddisclosednopathognomiclesion, apart from the presence of Ancylostoma, which mightjustify another diagnosis. On the basis of these results, theparasiticnature ofSaint Gothard disease and,inamoregeneralfashion, of miners anaemia was universally and definitivelyrecognised, as Dr Bugnion summed up in 1881 in the BritishMedical Journall3 and in the Revue Medicale de la SuisseRomande4: "While the high temperatures in the tunnel andthelackoflightplayedapartinthedevelopmentoftheanaemiain the workmen, it can be stated that the most important partwas played by the ankylostoma, and I do not think that anyonetoday can argue against a statement which is based, not on afew articles innewspapers buton positive provenfacts."EpidemiologyAfter thesolutionoftheproblems ofdiagnosis and treatmentof the disease, it was now necessary to attack the problems ofepidemiologyand infestation, and to explain how it was that adisease characteristic oflowlands and hot or temperate climatescould manifest itself so dramatically in the very heart of theAlps. Even at that period those who studied the problem wereableto supply an answer that is still valid today about theBRITISH MEDICAL JOURNAL VOLUME 287 24-31 DECEMBER 1983various biological and ecological mechanisms underlying theSaint Gothard epidemic. We quote the clear and convincingarguments ofParonal":"The appearance ofAncylostoma dzuodenale at the very heart oftheAlps, at an altitude of 1155 metres above sea level . . is the moresurprising in that to date we knew only ofthe endemic areas ofthePo valley and the malarial zones. While it must be pointed out thatthe majority of the Gothard workers came from the provinces ofVenice and Upper Piedmont, a large number nevertheless camefrom the endemic areas. While this explains the transportation oftheparasite to a new area, it does not explain the magnitude ofits spreador the severity ofthe epidemic...."Waterflow was very slow, and water accumulated on the floor ofthe tunnel, particularly where oblique cuttings were made, and herethewatermightcomeup as farasthekneesorabove,andtheworkershad to spend several hours at a time under these conditions."In this way the extreme humidity ofthe tunnel and the excessivehumidity of the air, vitiated as it was by the fumes of explosives,and the high temperature in the tunnel (36-38"C), together with theexhalations of the men and animals working there, all conspired toproduce an environment similar to that of a swamp or a tropicalcountry."Butthe fact ofthe greatest importance in this question is that formany years the workers excreta had been allowed to accumulate inthe tunnel and had never been cleared away."If we consider the prodigious fecundity of the ankylostoma-insevere cases one may find 150 to 200 ova per centigram of faecalmatter-each patient spreads millions of ova of the parasite everyday. The rapidity of the development of the embryo and larva,favoured by the high temperature and humidity, the facility withwhich the encapsulated ankylostoma larvae are transported by water,in which they can survive for several weeks, as I have myself con-firmed, all these factors explain the spread ofthe parasite among theSaint-Gothard workers."ConclusionWe have tried to show how the epidemic ofanaemia amongthe Saint Gothard miners contributed to advancing our know-ledge of ancylostomiasis. Today we can say that the clinicalaspects ofancylostomiasis were first described in Europe underthe name of"miners anaemia," even though the condition is atropical one. Undoubtedly it was during the epidemic thatoccurred while boring the Saint Gothard tunnel that itwasfirst discovered that the features of Saint Gothard anaemiacorrespondedwiththose ofminers diseaseinotherregions,andthereafter that the pathogen causing "miners anaemia" wasnone other thanAncylostoma.The numerous parasitological studies carried out during theSaint Gothard epidemic gave rise to a further confirmatoryseries ofstudies inwidelydifferingcountries and environments.Perroncito himself at the end of 1881 showed the presenceBRITISH MEDICAL JOURNAL VOLUME 287 24-31 DECEMBER 1983 1945ofAncylostoma in anaemic workers in the mines of St Etienneand Valenciennes in France. The observations reported fromthe Saint Gothard tunnel were confirmed throughout theworld, by demonstrationofthe wide spreadofthe Ancylostoma,the essential factor in miners anaemia, and generally inancylostomiasis inhothumid countries.Ancylostoma were in fact successively reported in mines inAustria, Germany, Belgium, and Russia. Lutz found them atSao Paolo, in Brazil, in 1880-5, Stiles found them in NorthAmerica, andlaterA E BoycottandJ S Haldanefoundthem inworkers in the Cornish mines at Dolcoath and at Newcastleupon Tyne."5 For having inspired these studies in England,Professor Perroncito received a doctorate "honoris causa" inscience from the University of Manchester in 1905, with thecitation"onthe25thanniversaryofthediscoveryoftheparasiticnature and ofthe treatment ofminers anaemia.l6His work on Saint Gothard anaemia also brought him otherprizes and high honours: we shall mention merely the spon-taneous offer by De Sanctis, the Italian Minister for PublicInstruction,to support his work financially. We should alsorefer to his collaboration with the Academy of Sciences inBudapest to carry out studies on the miners of Chemnitz inHungary. Nevertheless, it was principally the therapeutic andpreventive measures developed and recommended after theepidemicat the Saint Gothard tunnel that were successfullyapplied in improving the hygiene ofmines and eliminating theAncylostoma."So outstanding successful were these preventivemeasures that when the Simplon tunnel was bored (between1898 and 1906) not a single case ofancylostomiasis was found,thanks to rigorous hygienic discipline.8Thephotograph is reproduced bypermission ofIstituto CantonaleBatteriosierologicoand the engravings by permission ofMary EvansPicture Library.ReferencesCCTA/WHO African Conference on Ancylostomiasis. Report. WHOTech Rep Ser 1963;No 255:5-27.2 Perroncito E. Observations helminthologiques et recherches experi-mentales sur la maladie des ouvriers du Saint-Gothard. C R SeancesAcad Sci 1880;90:1373-5.3 Concato L, Perroncito E. Memoria letta alla Regia Accademia Medicina.Giornale della Regia Accademia di Medicina di Torino 1880; Mavzo.(Quoted in Bugnion E. Rev Med Suisse Rom 1881;1:269-89, 405-50.)4Concato L, Perroncito E. Sur lanchylostomiase. C R Seances Acad Sci1880;90:619-20.5 Bozzolo C,Pagliani L. LetteradaAirolo. La Perseveranza 1880; 9 Mavzo.(Quoted in Perroncito E. La malattia dei minatori dal S. Gottardo alSempione: una questione risolta. Torino: Carlo Pasta, 1910.)6 Sonderegger A. Ankylostoma duodenale. Blatt fur Schweizer Aerzte1880;10:646-8.7 Sonderegger A. Die kranken Gotthardtunnel-Arbeiter. Bericht an dasEidg. Blattfur Schweizer Aerzte 1880;10:393-6.8 Lombard H-C. La maladie des ouvriers employes av percement dutunnel du Saint-Gothard. Archives des Sciences Physiques et Naturelles1880;3:516-30.9 Perroncito E. LAnemia dei contadini foraciai e minatori in rapportocollattuale epidemia negli operai del Gottardo. Studio e osservazioni,profilassi e cura. In: La malattia dei minatori dal S. Gottardo al Sem-pione: una questione risolta. Torino: Carlo Pasta, 1910.0 Perroncito E. Note sur laction de lextrait daspidium filix mas surles ouvriers du Gothard atteints doligemie epidemique. Rev MedSuisseRom 1881;1:163-8.1 Parona E. Lanchilostomiasi e al malattia dei minatori del Gottardo;note clinico-anatomiche. Annali Universali di Medicina et Chirurgia,Milano 1880;153:177-202.12Parona E. Lestratto etereo di felce maschio e lanchilostomiasi dieminatori del Gottardo. Osservatore, Torino 1881;17:19-49.13 Bugnion E. On the epidemic caused by ankylostomum among the work-men in the St Gothard Tunnel. BrMedJ7 1881;i:382.14 Bugnion E. Lankylostome duodenal et lanemie du Saint-Gothard.Rev Med Suisse Rom 1881;1:269-89, 405-40.15 Boycott AE, Haldane JS. An outbreak of ankylostomiasis in England.No 1.J Hyg (London) 1903;3:95-136.16Perroncito E. Addresson sorle points concerning human intestinalparasites. Conference held in the University of Manchester, on theoccasion of thebestowal of the title of Doctor of Science HonorisCausa.1905; 27 January. In: La malattia dei minatori dal S. Gottardoal Sempione:una questione risolta. Torino: Carlo Pasta, 1910.17Perroncito E. La malattia dei minatori dal S. Gottardo al Sempione: unaquestione risolta. Torino: Carlo Pasta, 1910.18 Volante G. Intorno alle condizioni igienche e sanitarie in cui si svolsevoi lavori della Galleria del Sempione. In: Perroncito E. Lamalattia deiminatori dal S. Gottardo al Sempione: una questione risolta. Torino:CarloPasta, 1910.jr4Nineteenthcenturyengraving ofdoctorandpatient.