NationalLibraryOfScotland/medical-history-of-british-india huggingface dataset:
32
LENGTH OF STAY IN HOSPITAL.
45. An analysis of the lengths of detention in the Viper Hospital during
the period 1st January to 19th February (healthy period) and during the
period 1st to 19th July (severe malaria prevalence) gave results as follows :—
Length of period of detention.
HEALTHY PERIOD (50 DAYS).
UNHEALTHY PERIOD (19 DAYS).
Number.
Rate per day.
Number.
Rate per day.
1 day .
.
.
.
.
7
.14
4
.21
2 days .
.
.
.
.
13
.26
61
3.21
3 "
21
.42
75
3.95
4 " . . . . .
38
.76
72
3.79
5 "
33
.66
77
4.05
6 "
33
.66
44
2.32
7 "
26
.52
22
1.15
8 "
.
17
.34
11
.57
Total 1 to 8 days
.
188
3.42
366
18.68
Total over 8 days
355
7.10
112
5.89
There is therefore no increase but even a reduction in the number of cases
lasting over 8 days during the fever season. The greatest increase during
severe malaria prevalence is in the number of cases lasting two to five days.
This is important as showing that the increase in the number of admissions
during the fever season is not accompanied by a corresponding increase in the
intensity of the cases. It would seem from these figures that most of the cases
admitted even in the height of the fever season in a bad year were mild
attacks of malaria. Otherwise the patients could scarcely have been discharged
even into the convalescent gang in such a short space of time. Such a state
of affairs is more what one would expect with an increase in the number of
relapses than with airy great increase in the intensity of fresh infections.
With any great increase in the amount of transmission of malaria one would
expect a large increase in severe infections and even pernicious cases, i.e.,
along with an increase in the number of cases admitted there would necessarily
be pari passu an increase in their severity. How far one is justified in such a
view as the above can only be shown by more extended enquiry. But as will
be seen there are other considerations which point to the conclusion that re-
lapses play a large part in the malaria of the convict community.
FREQUENCY OF READMISSION.
46. In the last section it was seen that a very large proportion of cases
admitted to hospital remain in the wards only a very short time. It becomes
important to know to what extent these admissions are independent of one
another. Analysing 647 admissions for fever during the months January to
March 1909 the following information was obtained:—
Admitted for fever in the period
.
.
.
.
. 647
Showing 1 readmission
.
.
.
.
.
. 113
" 2 " 25
" 3 "
.
.
.
.
.
.
.
.
5
Total number of readmissions
. 178
The number of readmissions must necessarily be somewhat higher than
this because the period before the chosen time was not taken into consider-
ation.
In April 1909 out of 366 admissions for fever to Haddo Hospital 155 had
been in hospital for fever during the previous three months. The medical
history sheets of convicts also spews that frequent readmissions are common.
47. The frequency of readmission is important because if, as I shall shew
is probable, much of the fever in the Andamans consists of relapses, it indicates
the desirability of a policy of, as far as possible, curing each case admitted.
At present I do not think that treatment of this thorough kind is attempted.
How far thorough quinine treatment of cases could be carried out and what the
effect of this measure would be requires trial to ascertain.
ORIGIN OF INFECTION RESPONSIBLE FOR RELAPSES.
4 8 . E v e n a s s u m i n g t h a t m u c h o f t h e f e v e r a m o n g t h e l a b o u r i n g c o n v i c t s
is due to relapses, such evidence as can be obtained is against the view that
infection contracted before arrival is to any appreciable extent responsible.
Only convicts passed as fit are in the first place transported. The examination
of 96 new arrivals in the quarantine camp shewed only one case of enlarged
spleen and five cases with any appreciable degree of anæmia. Among 48 men
examined in the Central Jail (first six months of transportation) none
shewed enlargement of the spleen. In the next section it will be seen that the
average weight of the spleen of convicts who die at various periods after
coming to the Andamans undergoes an increase during the first three or four
years rising from an average weight of 12 oz. to 16 oz. or more. All these
observations point to the fact that there is a sufficiency or fresh infection
F
34
among the convict community in the Settlement to form the basis on which
such relapses as occur are founded.
VII.—The death rate.
49. The death rate per thousand for a number of years among new
arrivals, labouring convicts, and self-supporters is given in the following
table taken from the administration report for 1904-05.
YEAR.
New arrivals. Labouring convicts. Self-supporters.
1888
. . . . . . . .
180.7
3 4 . 3
1 9 . 6
1889
.
.
.
.
. . . .
81.8
2 6 . 9
2 1 . 7
1890
.
.
. . . . . .
34.8
3 4 . 2
21.5
1891
.
. . . . . . .
48.6
4 6 . 3
1 2 . 9
1892
.
.
.
. . . . .
51.2
5 4 . 9
2 4 . 9
1893
.
.
.
.
.
.
. .
41.5
3 1 . 3
1 4 . 7
1894
. . . . . . . .
18.1
2 8 . 8
2 4 . 9
1895
.
.
.
.
.
. . .
36.2
3 3 . 7
1 3 . 0
1896
.
.
.
. . .
16.7
2 7 . 6
9.7
1897
. . . . . . . .
22.0
2 8 . 4
1 3 . 6
1898
.
. . . . . . .
23.4
2 6 . 4
1 9 . 8
1899
.
.
. . . . . .
67.7
3 9 . 1
1 4 . 9
1900
.
.
.
.
. . . .
47.7
3 7 . 8
2 2 . 6
1901
.
. . . . . . .
41.9
3 7 . 7
1 5 . 7
1902
. . . . . . . .
101.5
3 2 . 7
1 4 . 9
1903
. . . . . . . .
66.3
2 7 . 1
21.5
1904 . . . . . . .
96.8
2 7 . 5
1 8 . 2
It will be seen that in past years the rates are especially high among new
arrivals.
35
A more detailed statement for certain recent years taken from the admi-
nistration reports is given below.
Length of residence.
Average number of convicts.
Number of deaths.
Death rate per mille.
1906. 1907.
1 9 0 8 .
1 9 0 6 .
1 9 0 7 .
1908. 1906. 1907. 1908.
Under 6 months
699
309
3 8 2
1 7
2 3
24.3 6.4
5.2
Over 6 and under 12. 1,303 837
6 9 4
3 9
5 3
29.9 6.0
4.3
Over 1 year and under
2 .
1,566 1,223
7 6 4
6 9
2 8
14
44.0 22.9 18.3
Over 2 years and
under 3.
1,391 1,279
1 , 1 9 2
6 8
3 3
29
48.8 25.8 24.3
Over 3 years and
under 7.
3,094 4,435
4 , 7 9 1
1 5 6
9 7
124 50.4 21.8 25.9
Over 7
6,303 6,317
6 , 2 0 2
2 1 0
1 7 5
202 33.3 27.7 32.6
In these years therefore the highest rates are not among new comers but
in convicts who have been a number of years in the Settlement. Without
more elaborate enquiry than I was able to undertake it is not possible to do
more than surmise that the change is due to the increasing attention given to
the medical aspect of the treatment of convicts, especially the attention now
given to the conditions affecting new arrivals.
PART PLAYED BY MALARIA IN THE DEATH RATE.
50. From what has been said regarding the effect of malaria on the sick
rate it might be expected that in the death returns this disease would also
figure largely. Such is not the case as will be seen from the following
statement:—
NUMBER OF DEATHS FROM VARIOUS CAUSES.
1903.
1904.
1905.
1906.
1907.
1908.
Malaria .
.
.
32
62
51
48
32
31
Dysentery
.
.
97
111
187
72
45
61
Phthisis .
.
.
110
114
93
89
75
94
Pneumonia
.
. .
65
39
68
72
62
57
Other causes
. .
75
100
103
73
91
94
Percentage of deaths
due to malaria
.
8
14
10
13
10
9
It will be seen that whilst malaria forms from 50 per cent. to 70 per cent.
of the total admissions to hospital it is only responsible in the records for from
10 per cent. to 14 per cent. of the deaths.
F2
36
5 1 . T h a t m a l a r i a s h o u l d h a v e s o s m a l l a d i r e c t e f f e c t u p o n t h e d e a t h r a t e
is in keeping with what has already been said regarding the comparative mild-
ness of the average attack of this disease among the convicts. It seemed prob-
able, however, that the real effect of malaria in enhancing the death rate is
greater than is indicated by the number of deaths directly due to this disease.
To determine the existence and nature of any such indirect effect the
records of autopsies were examined. These are of special value in the Settle-
ment since with very occasional exceptions an autopsy is made upon every case
of death among the convicts.
These records show conclusively that as regards the returns made under
dysentery, phthisis and pneumonia, diseases to which the bulk of deaths are
ascribed, there is no question but that death has been due in the great majority
of cases to the disease returned. Neverthless one was impressed with the much
greater importance of " Pneumonia, " as a cause of death than is gathered from
a perusal of the tabulated statistics.
52. The number of deaths returned as pneumonia in the post-mortem
records of the three large hospitals Viper, Haddo and Bamboo Flat are shewn in
Table XII.
TABLE XII.—RETURNS FOR DIFFERENT CAUSES OF DEATH, 1907 TO 1911.
Pneumon-
ia
Dysen-
tery.
Phthi-
sis.
Malaria.
Fever wit
h jaundice. Other.
Total.
Percentage
of
Pneumonia.
Percentage
of
Dysentery.
Viper
123
59
30
29
18
121
380
Per cent.
32
Per cent.
16
Haddo
105
146
44
23
6
144
468
22
31
Bamboo Flat
75
68
264*
34
19
61
...
...
...
* Includes deaths in phthisis ward for whole Settlement.
In addition to these there are however a number of deaths due to the com-
mon sequelæ and concomitants of pneumonia which should also be included
under this heading. Such cases were most of those returned as gangrene of the
lung, pericarditis, or pleurisy. Empyema is also obviously most likely to be
a sequela of lobar pneumonia. Not infrequently cases returned as remittent
fever and acute diarrhœa (often admitted in extremis) show hepatisation of the
lung and are probably often primary pneumonia cases. Cases returned as
dysentery also not infrequently show hepatisation of the lung and in such cases
it is probable that pneumonia was the actual cause of death. At Viper such
cases would increase the rate for pneumonia by about another 25 per cent.
37
(Out of 131 consecutive records of autopsies 53 were cases returned as pneumo-
nia and another 14 were cases with post-mortem evidence of this disease or due
to its common sequelæ). The total effect of pneumonia as an actual cause of
death is therefore very considerable.
Viper draws its patients from what is undoubtedly the most malarious part
of the Settlement (Western District). Haddo, on the other hand, draws most of
its cases from the comparatively non-malarious stations about Aberdeen. It
will be seen that the proportion of deaths from pneumonia in Viper is remark-
ably high compared with those for any other disease whilst at Haddo dysentery
becomes a more prominent cause of death.
The following tables (Tables XIII and XIV) give the average weight of the
spleen for different diseases and areas compiled from the post-mortem records.
It will be seen that the size of the spleen in pneumonia deaths is even greater
than that in cases returned as deaths from malaria (mostly chronic infections).
This disease in fact holds quite a unique position in regard to the increase in
weight of the spleen.
That this increase in the average weight of the spleen is not an effect of
pneumonia per se is shewn by the figures given in the last lines of the tables.
These are the rates shewn in cases of lobar pneumonia in the records of the
Calcutta Medical College obtained from information very kindly abstracted
for me by Major L. Rogers, I.M.S.
TABLE XIII.
Pneumonia. Dysentery. Phthisis. Chronic
malaria.
Fever with
jaundice.
Othe
r c a u s e s .
VIPER
No. of cases
112
46
29
27
18
108
Average weight
spleen in ounces.
20.1
12.8
14.2
17.3
17
15.4
HADDO
No. of cases
75
111
34
14
6
112
Average weight
spleen in ounces.
24
12.9
10.7
22.1
19.5
14.6
BAMBOO FLAT. No. of cases.
70
67
196
34
17
59
Average weight
spleen in ounces.
22.9
11.5
14.3
21.4
15.6
16.4
CALCUTTA
No. of cases
60
...
...
...
...
...
MAJOR ROGERS Average weight
spleen in ounces.
10.7
...
. . .
...
. . .
. . .
3
8
TABLE XIV.
Under 1 lb.
Over 1 lb.,
and
under 2 lbs.
Over 12 lbs.,
and
under 3 lbs.
Over 3 lbs.
I
Viper . .
Pneumonia.
.
46
51
12
3
Dysentery
.
.
34
9
2
1
Phthisis
21
6
1
1
Malaria
13
11
3
0
Other causes
74
34
15
3
H
a d d o
Pneumonia .
.
15
39
16
5
Dysentery
.
73
37
0
0
Phthisis
28
6
0
0
Malaria .
.
.
2
9
0
2
Other causes .
.
62
42
12
3
Bamboo Flat .
Pneumonia .
21
30
17
2
Dysentery
.
.
54
10
3
0
Phthisis
125
65
3
3
Malaria .
.
.
14
12
7
1
Other causes . ..
40
28
5
1
Calcutta .
. Pneumonia .
.
45
12
1
2
It is difficult to see what other conclusion can be drawn but that there is a
close association between malarial infection and the incidence of fatal lobar
pneumonia. My clinical experience in the Settlement upholds this view for
among the cases admitted to hospital with parasites (Table II) two later deve-
loped a fatal pneumonia. One other severe malaria case was admitted for
bronchitis.
Neither dysentery nor phthisis shews any enhancement of the average
spleen weight and the former disease even shews a distinct lowered average
weight, a fact which is explained in the next section.
EFFECT OF DIFFERENT DISEASES IN RELATION TO LENGTH OF RESIDENCE.
53. The results of a determination of the average spleen weight for differ-
ent diseases at different periods of residence are given in Table XV.
3
9
TABLE XV.
Convict numbers in
groups of thousands. Over 30,000.
28,000
to
30,000.
26,000
to
25,000.
21,000
to
26,000.
15,000
to
21,000
10,000
to
15,000.
1
to
10,000.
Approximate time of
deportation.
1908
onwards.
1906
and
1907.
190
4 an
d 1905.
1901
to
1904.
Prior to 1901.
Number of autopsies,
1910 and part of 1911.
73
81
55
76
78
71
22
Average weight of spleen
of autopsies in 1910
and 1911 (in ounces).
1 4
15
16
19
19
18
14
Percentage of deaths
due to Pneumonia.
11
24
28
32
27
15
Percentage of deaths
due to Dysentery.
38
27
7
9
4
0
Percentage of deaths
due to Phthisis.
15
15
25
23
2 8
31
Percentage of deaths
due to other causes.
36
34
41
36
41
54
Number of autopsies in
1909.
26
43
35
43
36
27
7
Average weight of
spleen in autopsies in
1909 (in ounces).
12
16
17
18
20
24
16
Percentage of deaths
due to Pneumonia.
0
14
23
27
16
26
Percentage of deaths
due to Dysentery.
61
31
20
9
5
13
Percentage of deaths
due to Phthisis.
11
18
22
2 4
24
22
Percentage of deaths
due to other causes.
28
37
35
40
5 4
39
This table is compiled on the basis of the serial numbers which are given
to convicts on their arrival at the Settlement. These numbers enable one to
judge of the length of residence with sufficient accuracy for our purpose.
40
It will be seen that the spleen weight in the case of those dying increases
during the first few years rather rapidly, and then more slowly to a maximum
of about 18 oz.
It will also be seen that whilst pneumonia, phthisis and other causes reach
their maximum percentage in those who have been a number of years in the
Settlement, dysentery exhibits a remarkable relative prevalence in the first few
years.
Pneumonia especially shews a small relative effect on new comers and a
maximum effect in those who have been about ten years in the Settlement.
This corresponds with the period of greatest average spleen weight.
Early corners are chiefly resident in the comparatively non-malarial
Aberdeen area and the low average spleen weight in dysentery may be partly
at any rate due to this fact. Phthisis, however, shows a delayed incidence as
great as that of pneumonia though the average spleen weight is only about
half w hat it is in this latter disease.
The relation of pneumonia to malaria therefore seems quite a definite one.
Judging by the results of the enquiry dysentery shows very little relation to
malaria.
SOME SPECIAL DISEASES THE CONNECTION OF WHICH WITH MALARIA IS.
UNCERTAIN.
54. In the annual sanitary reports of the Settlement mention is frequently
made of a fatal fever of short duration associated with jaundice. Unfortu-
nately no cases of this fever occurred during my stay in the Andamans and the
following information regarding its nature are based only on information
contained in hospital reports and upon some films of blood and organs kindly
furnished me by Major Woolley, I.M.S.
The symptomatology of the disease is that of a severe fever of short duration
associated with jaundice and most frequently fatal. It occurs especially
among the self-supporters of certain villages, the most notable being Port
Mount and old Namunagahr (very malarious site since abandoned). It has also
occurred at. Dundas Point presumably among labouring convicts.
Cases picked out for me from the admission books as special cases by the
Senior Medical Officer had. the following seasonal distribution. In 1907 two
cases occurred in July, in 1908 four cases occurred respectively in July, August,
October and November. In 1909 one case occurred in June, three in July and
one in August, September and November, respectively. Two cases had occurred
in July 1911 shortly before my arrival. It will be seen that the local seasonal
distribution closely follows that of malaria. But the average spleen weight in
these cases works out at 13.7 oz. which is not above the average.
41
In films of the organs of one case, which had deteriorated greatly in. the
moist damp atmosphere, I found a small amount of what might have been
malarial pigment, but the appearances were not those of a fatal and acute
malaria.
Similarly in some excellent blood films of a recent case (a European living
near Port Mouat) sent to me by Major Woolley, I found after long search only
one small malignant tertian ring and no evidence of a severe and fatal malarial
attack.
The question of Blackwater fever occurred to me but in the notes accom-
panying the last mentioned case it is definitely stated that hæm oglobinuria was
not present. Nor could I find any of the usual evidences of this disease
(engulfed red cell shadows, etc.)
It is useless to theorise regarding this disease the nature of which still
requires elucidation.
55. Cases of sever e anæmi a r esul t i ng i n many cases i n deat h ar e not
uncommon among the labouring convicts. The nature of these cases is often
very uncertain. They have been returned as malarial anæmia. The average
weight of the spleen in such cases is not high (13.3 oz.) and. in one typical case
seen by me post-mortem this organ was normal in size and appearance, and
there were no parasites or malarial pigment in the organs.
Prolonged search in four severe cases in hospital failed to shew malarial
parasites and the leucocyte values were not those of malaria. A very charac-
teristic feature of the blood picture in all four cases was the large size of the
red cells and the presence of immense polychromatic cells such as I have not
seen either in malaria or following Blackwater fever. The nature of these
a n æ m i a c a s e s i s u n c e r t a i n a n d t h e i r r e l a t i o n t o m a l a r i a d o u b t f u l .
GENERAL CONSIDERATIONS ON THE DEATH RATE.
56. It seems clear that whatever effect malaria may have in an indirect
way upon the death rate among the labouring convicts it is by no means the
essential reason of the high mortality. The death rates for phthisis and
dysentery diseases which we have seen do not shew any special relation to
malaria, give rise to about half the total deaths. When the amount of care
taken in regard to feeding, housing and sanitary matters is considered it seems
very probable that the most fundamental cause of a high mortality is the
profound effect upon men of imprisonment and. transportation. In addition
there is the fact that a very large collection of men have been congregated
under very artificial conditions within a small area.
The problem of malaria among the labouring convicts from what has been
shewn in this report would seem to be bound up very closely with the general
G
42
conditions affecting the health of the community. Over and above any direct
attack made upon this disease there is therefore the necessity of attending to
everything affecting the general condition of the convicts.
Such a view is important since it enables one to see that an abundant
dietary and comforts are not altogether a matter of mere luxury, but under
peculiar conditions may be a medical necessity if a reasonable death rate among
the community is aimed at. Economy under these circumstances should not
be short-sighted and a saving made on a dietary, estimated to be just sufficient,
may well lead to ultimate loss when hospital expenditure and labour efficiency
with all that this means is taken into account.
V I I I . — S u m m a r y a n d . c o n c l u s i o n s .
The observations recorded in the preceding sections enable some very
definite conclusions to be drawn regarding malaria in the Andamans.
MECHANISM OF TRANSMISSION.
57. The chief carrier of malaria in the Settlement is Nsm. ludlowi,
a species which breeds in and about salt swamps and was not found. at a greater
distance from salt or brackish water than half a mile.
The species of parasite proved to be carried by this anopheles was malig-
nant tertian. It is probable as happens with other species that it carries all
forms of the parasite.
Whether any part is taken in the transmission of malaria by the other
common species Nsm. rossi and My. barbirosiris is doubtful. In any case the
latter species could only be an important carrier within the forest. The mere
clearing of the land has made it unimportant even in regard to numbers.
58. Owing to the distribution of Nsm. ludlowi, malaria in the Settlement is
confined to a belt around the margins of the harbour and is absent or nearly so
from villages more than half a mile from the sea coast or the salt swamps
associated with this. This freedom from malaria is seen even in inland villages
situated on the margins of swamps, amidst rice-fields and near jungle.
In the case of some villages malaria was found in the portions lying
nearest the sea but not in the inland portions.
59. The endemicity even within the malaria belt is not strikingly high
and only one large village (Port Mouat) showed a spleen rate of over 50 per
cent.
60. This moderate endemicity is associated with a moderate prevalence
—only of anopheles.