NationalLibraryOfScotland/medical-history-of-british-india huggingface dataset:
Anæmia of coolies.
xiii
the anæmia due to anchylostomiasis and of other conditions which
are essentially produced by loss of blood, while the high hæm
o - g l o b i n v a l u e o f t h e a n æ m i a p r o d u c e d b y m a l a r i a i s a c c o u n t e d
for by the fact that the hæmoglobin of the red corpuscles which
are destroyed by the fever is not lost to the system. In anæmia,
which is brought about by improper or insufficient diet, it is only
to be expected that the hæmoglobin should be reduced more than
it is in malarial anæmia, but less than that due to hæmorrhages.
This is exactly what we see in this case, and I have also met with
it in one or two others in which the anæmia was also produced
by bad diet. These observations then confirm the importance of
improper diet as a cause of anæmia, and also seem to point to the
probability of an examination of the blood being likely to be useful in
a study of anæmia of coolies. The case above described improved
rapidly under treatment with iron combined with a liberal diet;
but unfortunately she died of cholera two or three months later, just
before my return to Nowgong after a long tour, so that I did not
have an opportunity of recording the extent to which her blood
improved while she was under treatment.
While on the subject of the blood changes found in anæmia of
coolies, it will be well to record some observations which prove the
primary importance of proper after-treatment of this class of cases.
I re-examined five cases of anæmia due to anchylostomiasis in
garden coolies after an average of eight weeks from the date of the
removal of the worms by thymol, but they had only been treated for
a few days in hospital and then had returned to work, although in
two of the cases iron had been continued for three weeks in all,
including the time they were at work. The average gain in the
hæmoglobin in the eight weeks since the previous ex aminations was
7 per cent. only, and on enquiry they were all doing half or less than
half work, and would have continued doing so for a long time. Now
Dr. Sandwith, who has recorded the result of the after-treatment of
173 cases of anchylostomiasis, found that during an average stay of
thirty days in hospital after the administration of thymol, the gain of
hæmoglobin varied "from 22 to 32 per cent., and probably continued
when the men became out-patients." The advantage of the complete
rest in hospital, combined with treatment with iron, etc., is very
marked here, and when it is considered that the anæmic tea garden
coolies were only doing half or less than half work, it is obvious that
if they had been given complete rest for one month, together with
b 2
proper medicinal treatment, the resulting improvement in their blood
and consequent increase in their power of working would have been so
great, that in another month or so they would have made up for the
lost time, and after that there would have resulted a great gain of
labour, to say nothing of the doing away of the considerable risk of
a coolie in such a state dying from some inter-current disease
from which he would recover if in fairly good health. These observa--
tions then show the immense importance of suitable after-treatment
in cases of anæmia of coolies, whether produced anchylostoma or
other cause, in addition to the mere giving of thymol, and also that
rest is of just as much, and in some cases of even more importance
than medicines in the treatment of anæmia of an advanced type.
One other point has been brought out as a result of my investi--
gation which must be referred to before passing on to see what
practical lessons can be learnt from the points that I have mentioned.
I was much surprised to find how poor the natives of Assam were in
hæmoglobin as compared to the European standard of Dr. Gower's
instrument (the instrument which was used was checked with another
one, and found to be correct, so there is no doubt about the accuracy of
the observations), and that they were much poorer in this element than
Europeans living under the same climatic conditions, although this
latter point is readily explained by the fact that the meat diet of the
latter contains much more iron than the diet of natives does. Still
more important is the fact that in some cases the hæmoglobin may be
reduced to one-half without the mucous membranes showing any sign
of anæmia, so that in any case where pallor of these is well marked, a
severe degree of anæmia is present, while the slightest appearance
it denotes a very considerable deficiency of this the most essential
element in the blood. This is a point the practical importance of
which cannot be too strongly insisted on, for if only all cases of anæmia
could be caught in the early stage and treated properly until the
blood is restored to something like its normal state, then advanced
and fatal cases could never occur, and instead of getting but half or
less work from an anæmic coolie, or in the more advanced stages
having to spend money on both food and medicines for him, with no
prospect of any return, a few weeks' or even days' rest and medicine
in the early stage would prevent all this, and would eventually save
much more than it would cost.
Now I am fully aware that only too often the coolie does not
come to hospital until he is suffering from a marked form of anæmia,
Anœmia of coolies.
xv
and also that some of the worst cases are among those who have
come up to the province in an anæmic condition, and who have never
done a day's full work on the garden since their arrival; but this
is obviously a mistake in the recruiting, and only confirms most
strongly my point that prevention is better than cure, and that rest
in time saves much labour in the end. Although the ideal aimed at
in the following suggestions based on the foregoing facts may not
always be attainable in every instance, yet I am convinced that the
more nearly they are carried out on any garden, the less will be
the loss of life and labour due to what should be, in its more severe
forms at least, largely a preventible disease, and the greater will be
the gain on any expenditure that may be incurred in carrying them
cut. Most of them are in active use in one or other garden, but I
know of none in which all of them are carried out. It will simplify
matters if anæmia cases are divided up into three classes, namely,
slight, well marked, and extreme.
In order to detect the cases of anæmia while they are still in an
early stage, it is highly desirable that all coolies should be examined
for anæmia, say, about once a month, more especially during the rainy
season for their first two years on the garden, as it is during this period
that. quite 50 per cent. of the cases begin. This inspection could be
carried out in the lines at the morning roll-call or other convenient
time, and would not take very many minutes. All that would be
necessary in these cases, would be to treat such of them as it might be
thought advisable with thymol, and to see that they took an iron tonic
for a few weeks, which might be given in the lines before and after
going out to work, as has been done in one or two gardens with some
of the cases which had previously failed to improve after the thymol
treatment as detailed above, with the best results. Special efforts
might be made on these lines at the end of the rains when the busiest
season is past.
In well marked cases of anæmia, these simple measures will not
be sufficient to secure the most rapid, and consequently the most
economical, results. Rest from work must also be given for a time,
and it is here that improvement is most to be desired, and will doubt--
less be brought about when its importance is more fully recognised.
The difficulty is that anæmia most often begins in the rainy season,
which is just the busiest time, but a week or two of rest combined
with medicinal treatment as soon as well marked anæmia is discover--
ed, will be very soon made up for by the increased power of work,
Appendix No. 1.
which will result instead of a gradual but sure diminution of the small
account of work that is being done to be followed by sooner or later
by its entire cessation for a much longer period than would have been
necessary in the first instance. Anyone who will estimate the
hæmoglobin in a few cases of apparently slight anæmia will, I am sure,
be speedily convinced of the necessity for rest in addition to
medicine in their treatment, while the figures which I have given
above, show the practical importance of it in the anæmia due to
anchylostomiasis after thymol has been given. It must not be for-
-gotten that when once a coolie has become anæmic, he will be utterly
unable to earn any extra pay by doing more than the allotted task, so
that if he had been previously doing so, he may become unable to
afford as good a diet as he has been accustomed to, and that just at
the very time that he is in urgent need of a better one. For this
reason, if it is not quite certain that any particular coolie who has
become anæmic, is supplying himself with a sufficient diet,—and the
proper amount of nitrogenous food must be taken into account as
well as the actual quantity,—then it will be of the utmost importance
that he should at once be put on the "hotel system," and a full and
physiologically complete diet ensured. This is, I am sure, of just as
much, if not of even more, importance than any medicine not exclud--
ing iron itself, for what is the use of pouring iron into a man who is
living on a diet which in itself will be an efficient cause of anæmia.
In the most advanced stages of anæmia the above measures will
again be of primary importance, but one or two others may also be
indicated. Thus, if dropsy be present much good may be done by
the use of Southy's tubes for the removal of the œdema from
the legs and other parts of the body. Caution must be used in the
administration of thymol in such cases, and cardial tonics, of which
strychnine will be the safest and best, will be indicated for the
dilation of the heart, which is nearly sure to be present. It is in
these cases that the microscope is of the greatest use in deciding if
anchylostoma are present in any numbers before thymol is given.
In these cases once more the primary importance of absolute rest,
even to the extent of putting the patient to bed, and, if necessary,
placing a sick attendant over him to see that he stays there,
must be insisted on, and I was much interested to hear from Dr.
Elliot, of the Jorhat district, that he had recently carried this out in
two cases of very advanced anæmia, in which the patients had done
no work for months, and yet had made no progress at all, with the
Anœmia of coolies.
xvii
result that at the end of two months he could not find a trace of
anæmia in them; and these people who would otherwise have had their
names cut and been lost to the garden after great expense had been
incurred in feeding and treating them for many months, became once
more healthy working coolies. This is a measure which should be
carried out in all very bad cases of anæmia, and together with good
feeding would make the loss of either the permanent labour, or the
life of a coolie from anæmia of much rarer occurrence than it is at
present, I feel sure that these various points only need be broughtto
the notice of such as do not already carry them out, in order that
they may be given a fair trial, which could only lead to their more
general adoption than is at present the case.
LEONARD ROGERS, M.B., B.S., London, F.R.C.S., Eng.,
Surgeon-Captain, I.M.S.
xviii
APPENDIX NO. II.
ON THE SPREAD OF KÁLA-ÁZAR, AND HOW TO CHECK IT.*
As the disease called kála-ázar is still spreading slowly, but
surely, from one village to another and from one district to another,
and as it has been doing so for many years, the Government caused
an inquiry to be made into it. As a result of this inquiry, many
facts about the way in which the disease is carried from one place to
another, have been found out. It is therefore desired to instruct and
teach the people how the disease is spread, so that they may be able
to know how to prevent the infection being introduced into their
villages. This little book has been written and distributed for this
very purpose, and if the people will be careful to carry out the in--
structions contained in it, very much may be done to check the
further spread of this deadly disease.
In order to prevent cases of the disease being brought into villages
which have been previously free from it, it is
necessary that the villagers may be able to
recognise it and to take the proper steps to
prevent it before it gets bad in the village. It has been found
that villagers do very soon recognise the disease as a different
kind of fever to that which they have always been accustomed
to before the introduction of kálá-ázar into their villages. It
may be told from the ordinary fever in the following ways: the
ordinary fever lasts usually for a few days only, generally not more
than ten days, and then the sufferer gets well again, and it is only
in a few of these cases that death occurs, and then it will take
place within a few days. This is the kind of fever that the people
have always been accustomed to as long as they remember. Now,
the fever of kálá-ázar is quite different to this, for it goes on and on
for from two to four weeks at a time, and then after stopping for a
time it begins again and lasts for several weeks more. By this time
the spleen will have become enlarged, and the sufferer will get thin,
especially in the face and arms. He will often look fairly well, and
not be in distress, and may eat fairly well, and yet all the time his skin
will be hot. He will also become gradually bloodless, yet his face and
skin will get darker than it was before his illness. His feet may
* This is intended to be translated and distributed in the villages in the form of a pamphlet.
How to recognise the
disease.
Spread of kála-ázar, and how to check it.
x i x
now begin to swell, and he will continue to get fever, and
will waste away until he dies. Instead of only one or two cases
dying out of a great many, as in the case of the ordinary fever,
nearly all of the kála-ázar cases will die, and only very few will
recover.
But there is another way in which it may be known that kála
-ázar has begun in a village, because when one man dies in a house
another is nearly sure to get the disease, and one who lives in the
same house, or who often visits the first case during his illness will
soon fall sick, and after some months will die in the same way. This
tendency to attack several members of the same family is the most
definite characteristic of the disease, and one which marks it out as
something quite different from the ordinary fever.
It is very important to know how the disease first begins in a
village, as then it will also be known how it
may be kept out. There are several ways in
which it is introduced. The most common one
is by some person who is suffering from the disease coming to live in
a village where there were no cases previously to his arrival. He
generally comes to live with some relation, often in the hope that the
change of air from the village in which he contracted the disease
will do him good, and perhaps cause the fever to leave him. He will
generally therefore have suffered from the fever for a long time
before he comes, and so he will present the typical appearance of the
disease, and his face and extremities will be thin, while his belly will
be prominent owing to the enlargement of the liver and spleen, by
which characteristics it will be known that he is suffering from
kála-ázar. Another common way is for a person of a healthy village
to go and live, perhaps for a week or two, or even for a few days
only in an infected village, and then to return to his own village with
fever, which goes on and on until it is evident that he is suffering from
kála-ázar. After he has lived in the village for some weeks, espe-
-cially if it is during the rainy season, and he is still suffering from
fever fairly regularly, one or more of the inhabitants of the house
in which he is living will also begin to get fever of the same persistent
type, and then others in the village, especially those who visit this
house will begin to suffer, and there will be more deaths than usual
from fevers during the rainy season, while during the following cold-
weather months it will be noticed that the fever runs on later than it
usually does at this time of the year. It will then be certain that the
C
The way in which it is
introduced into villages.
dreaded disease kála-ázar has broken out in the village. Another
common way in which the disease is introduced into a village is
by either one of the residents of this village going to visit a relative
who is suffering from the disease in another neighbouring village,
and perhaps stopping a day or two in his house with him. He then
returns suffering from fever, which at first is thought to be ordinary
fever until it goes on and on, and he begins to get the symptoms
of kála-ázar, while others of his household and others in the village get
the disease in the same way as in the previous instance. Sometimes
it may be introduced by a person who has the fever coming to visit a
relative in a neighbouring uninfected village every now and then for a
day or two, although he does not regularly live in the village, but
during his visits some one in the house contracts the fever, and it
spreads as before. Instances have been met with in which the disease
was introduced in all of these various ways. Sometimes the
disease does not appear in a household until some time after a person,
who had the disease and had been living in this house, had left
it again and returned to his own village, so that in such a case the
house itself must have been infected during his stay, and later
on the affection broke out in the house, usually during the rains.
As soon as several cases have occurred in a village, it will spread
steadily through it, as there are plenty of opport-
unities for infection to take place. It will be
worse during the ordinary fever season, which is in the rainy months,
but as soon as the cold weather sets in, and the ground becomes
dry, the fever will become less, and those cases which have not died
will often lose their fever for a time. As soon as the rain begins to
fall again in April of the next year, fresh cases of fever will begin to
occur again. This shows that the infective agent has got into the
soil, but it is dried up during the cold season, but comes to life again
and causes a new outbreak of the disease as soon as the ground be-
-comes moist and warm. Both the houses and the soil around them
then have now become infected, and as long as the people remain in
this infected place, so long will they continue to suffer severely from
the epidemic until it has been present among them for six or seven
years, and a great many of them have died of the disease, while
others of them are very ill with it. Whole families will die of
the disease, or only one or two children may be left, and when
these are taken into another house, the fever may appear in that house
also.
The course of the disea-
-se in an infected village.
Spread of kála-ázar, and how to check it.
xxi
Now we know in what way the disease is carried from one village
to another; we also know how to prevent the
infection being introduced. When the disease
is first beginning in a district some of the larger
places, which have much traffic with those parts where the disease is
bad at the time, will be the first to become infected by it through
persons with the fever coming to live in these places from the infect--
ed districts. As soon as it gets bad in these larger places, it will
begin to break out in some of the smaller villages near them by
persons from these villages going to stay for perhaps only a few days
in these infected places, and returning to their villages with the fever
on them, and subsequently others in the village will get it. The infec-
-tion spreads in this way chiefly during the rainy season, extending
from the fall of the first few. inches of rain in April or May up to the
end of October. If then a village wishes to prevent the disease being
introduced among them, it will be necessary for them to find out
what villages near them are affected by the disease, and to cut off
all communication with them as far as possible. To carry this
o u t t h e y s h o u l d n o t a l l o w a n y o n e f r o m t h e a f f e c t e d v i l l a g e s t o v i s i t t h e m ,
nor should they visit any one in these villages, even if they are re-
latives of theirs. It is especially important that any of the villagers
who may have to visit a neighbouring large place or market town in
which the disease is present, should be very careful to avoid sleeping
in this infected place if they can possibly avoid it, and this is especi--
ally the case during the rainy season when the disease is most active.
When any village has many other affected villages around it, it is still
possible to prevent it being introduced into their village by cutting
off all inter-communication with the infected villages, and even when
one part of a village is attacked by the disease and the other parts
cut off all intercourse with the infected part, the other parts
may escape the introduction of the disease into their part of the
village for several years, or even entirely, Several instances of this
have been met with during the course of the Government inquiry
into the disease, so that it is easy to prevent the spread of the disease
if only the proper precautions are taken by the people themselves, as
they have successfully done in some instances. In one of the
paras of a village which so escaped, the headman forbade those of the
villagers who lived in his para to have any communication with the
other infected paras, and would not allow them to visit their own
relatives who were sick of this infectious disease, in those parts of the
How to avoid infection
of a village.