NationalLibraryOfScotland/medical-history-of-british-india huggingface dataset:
iv
Appendix No. I.
That anchylostomiasis can and does cause anæmia which, unless
detected and properly treated, will by itself cause death, is an
undoubted fact, but the liberal use of thymol has, to a very great
extent, robbed this disease of its terrors, while the nearly universal
introduction of pure water-supplies on tea gardens has largely
reduced the chances of very large numbers of the parasites being
introduced into the digestive track within a short time, for, although
the infection may be due in some cases to the swallowing of earth
containing the encysted or rhabditic form of the worm (whichever
may be the correct view of the development of the parasite), it can
only occasionally happen that several hundreds can be rapidly intro
-duced in this way. That anæmia of coolies due to anchylostomiasis
is much less common than it was a few years back, is the opinion
of both the most experienced Civil Surgeons as well as of the pri
-vate practitioners in charge of gardens whom I have met. This
improvement has taken place in spite of the fact that, although
latrines are now frequently supplied as a result of the recommend
-ations of inspecting officers, they are little if at all used (for to
force the coolies to resort to them against their wills, is quite im
-practicable), which seems to show that the decrease in the disease is
due chiefly to the improved water-supply, and hence affords an addi
-tional argument in favour of the more commonly-held view which
attributes the main part of the infection to water.
Now it must constantly be borne in mind that the best writers
on the subject of anchylostomiasis admit that as many as five hun
-dred anchylostoma must be present for from six months to a year
in order to cause anæmia in a healthy man. Although it is also
true that at the time of his death very few, or even none, may occa
-sionally be present, especially if he has had repeated doses of thymol,
yet, on the other hand, if a series of cases be examined, a large
number will be found in the majority of them. Again, it must be
pointed out that the worms cannot multiply within the body, but
every one must be introduced through the mouth in a partially
developed form, for I find this is not always understood by planters.
My work on the blood changes given in the fourth section of
this report proves that the essential factor in the production of
the anæmia of anchylostomiasis is the daily loss of blood, while dys
- p e p s i a i s a l a t e a n d c o m p a r a t i v e l y u n i m p o r t a n t s y m p t o m , f o r i t i s
a common experience to see a coolie in a fairly advanced stage of
the disease with marked dropsy regain his appetite within a very
Anæmia of coolies.
v
few days of his worms being removed by thymol, and to be quite
free from the discomfort after meals, which used to trouble him
greatly before.
That anæmia is the main cause of death in anchylostomiasis is
proved by the fact that in five successive fatal cases, in which I esti
-mated with accurate instruments the exact state of the blood within
a few days of their death, the percentage of hæmoglobin (the colouring
matter and most essential part of the blood) was, respectively, 8,
16, 10, 8, and 7 per cent. of Gower's standard, while it is generally
admitted that if this necessary element falls below to per cent.,
recovery is scarcely possible, so that we see in all but one of this
series the anæmia was in itself fully sufficient to account for the fatal
termination, while in the other case death was caused by hypostatic
congestion of the lungs and extreme dropsy of the whole body, includ
-ing the chest wall and abdominal cavity. The fact that within the
last few years the disease has been described more than once as
pernicious anaemia by workers, who have overlooked the presence
of the anchylostoma, is enough in itself to show that this is the most
important feature of the affection. The beneficial effect of absolute
rest in bed in cases which are apparently in a hopeless state, as will
be more fully pointed out presently, taken with the well-known fact
that complete rest is essential for the recovery from the worst forms
of anæmia, also points in the same direction.
Granting then that the anchylostoma, when present in large
numbers and for a long period, are able by themselves to cause a
serious, and if not properly treated, fatal anæmia, the question
remains—How much of the anæmia now seen on tea gardens is of
this nature? And can these cases be distinguished from those due
to other causes?
But before passing on to consider these questions, I should like to
write something on the use of thymol in Assam at the present time.
I have already mentioned my belief in immense value of this drug,
and when I came up to Assam, nearly a year ago, I was quite pre
-pared to find that whatever kála-ázar was, anæmia of coolies was
practically entirely anchylostomiasis, and that the only thing needed
to cure it was thymol. A little practical experience soon dissipated
this beautifully simple idea, and I am now of the opinion that there
is more to be feared from the abuse of the drug in Assam than from
its neglect. To give an instance of what I mean. In the hospital
of one of the most up-to-date gardens which I have visited, as far
a 2
vi Appendix No. I.
as concerns good water-supply with pumps, cisterns, etc., I saw
some six or eight cases of advanced anæmia which were all regarded
as hopeless by the doctor in whose charge they were, and who sub
-sequently died. They had all been treated with liberal doses of
thymol, but instead of getting better as other cases on the same gar
-den who had been similarly treated had done, they became the
victims of an intractible form of dysenteric diarrhœa, became reduced
to living skeletons, very like the man in the centre of the group
of anæmia of coolies cases opposite page i. Now what struck me
about these cases was that some of them did not present an extreme
degree of anæmia, while some had a considerable enlargem ent of the
spleen, and others had formerly suffered from dysentery; in short,
their anæmia was due to different causes, but they had all been
treated alike with thymol. Now I would not be understood to blame
any one for this state of affairs; all I wish to point out is that in our
present state of knowledge, it is difficult to distinguish quickly and
certainly between those cases that are likely to benefit by the admin
-istration of thymol, and those in whom it will only cause disastrous
results (for the exigencies of tea-garden work will not permit of the fre
-quent use of the microscope), and I find in certain quarters the drug has
for this very reason fallen into undeserved discredit. In fact, nothing
has struck me so much as the divergent views which I have heard as
to the value of this drug, and what I would plead for is a greater
discrimination in its use. I had hoped to have found time, while
investigating the epidemic malarial fever of Assam, to try and differ
-entiate by means of the blood changes between those cases of
anæmia which are due to the anchylostoma, and are consequently
amenable to the thymol treatment, and those which are not, and
although I have not been able to go into the subject nearly sufficiently
to obtain any very definite results, yet the very few observations
that I have been able to make are so encouraging as to lead me to
record them here, in the hope that some of the private practitioners
of Assam may find time to make use of their opportunities of
research in this direction, which, I feel sure, will amply repay careful
study.
It is a well-known fact that anæmia of coolies is much more
common in the first two years after their arrival in Assam, than it is
subsequently, 33 per cent. of the cases occurring in the first year and
17 per cent. in the second. Now Dr. Dobson has found 100 or more
anchylostoma in 1.3 per cent. of 547 healthy coolies on their way up
Anæmia of coolies.
vii
to Assam, and between 50 and 100 in 3.7 per cent. more, although
he was only able to examine the stools which were passed in the first
five and a half hours after the last dose of thymol had been given, so
that it is certain that had he been able to examine all the stools passed
for twenty-four hours after the use of the drug, he would have found
considerable larger numbers, for Dr. Sandwith, as a result of some
special observations on the time after the administration of the drug
at which most anchylostoma are passed, came to the conclusion
that "if it is impossible to examine several motions, it would appear
more important to examine, specially those which are passed from six
to eight hours after the thymol."
In Dr. Dobson's cases then the stools were only examined before
the most favourable time for finding the worms, so that it may be
safely concluded that at least double the number that he found must
have been present in these healthy men, for, moreover, all the worms
are not expelled by one day's administration of thymol. It is then
evident that at least 5 per cent. of the healthy coolies who are im
-ported into Assam, have 100 or more anchylostoma in their intes
-tines on arrival at their destinations—a number which, although too
small to cause anæmia by itself, must nevertheless cause a consid-
erable strain on the reparative powers of the system. The same
must also be true of the coolies in their homes; but it is easy to see
that while they are under favourable conditions in a climate to which
they are accustomed, and getting the food on which they have been
brought up and while their work is of a light, intermittent and
congenial nature, they may be able to stand this strain as long as they
are not attacked by any other illness. On the other hand, when a coolie,
who has such a number of these blood-sucking parasites in his intes
-tine, comes up to a different, and in the case of most of them, a much
damper and in every way unhealthier, climate, when he is obliged
to subsist on a diet composed almost entirely of rice, although he
may previously have been a wheat-eater (in which connection it
is worthy of note that it is the North-Western and Central Provinces
wheat-eating coolies who suffer most from anæmia, so much
so that some managers will not take them at all in spite of the
fact that they are easier and cheaper to get than the jungle coolies
of Chota Nagpur, who stand the Assam climate best of all), when
he is obliged to work steadily, although the task exacted is by no
means a very heavy one, and when in the busy and unhealthy rainy
season he works for long hours, in order to make extra money,
Appendix No. I.
and perhaps leaves himself too little time to properly prepare his
meals, then he is unable to stand the loss of blood which formerly
the system was able to repair, and he consequently becomes anæmic.
If in addition he suffers from malarial fever, dysentery, or venereal
disease, any one of which is capable by itself of producing severe
anæmia, then an aggravated form of the affection is certain to
ensue. In this class of cases, again, thymol will be indicated, but
it must be given with greater care, especially if dysentery has
previously been present, and should not, I think, be repeated within
a short time, as a second administration may do much more harm
by starting dysenteric symptoms than it can possibly do good by
the removal of the very small number of anchylostoma which may
have escaped the first doses of the drug, and it is of far greater
importance that after treatment of the anæmic condition by drugs
and rest should be much more prolonged than it very often is on
gardens.
The latest views of Dr. Ruddock, who was the pioneer investigat
-or on the subject of anchylostomiasis in Assam, will be of interest
in this connection. In a very courteous answer to some questions
I put to him recently, he writes
—
"Of course, some of the cases (of kála-ázar) had the anchylostoma, but so has
nearly every native of Assam, whether indigenous or imported, and will continue to
do so until their habits are very different; but the harbouring of a few worms
does not constitute anchylostomiasis. A healthy person can support a fairly
numerous colony of them without damage, and I think it is only when he suffers
from some other disease which reduces his powers of resistance that the
presence of the parasite assumes importance."
The majority of the cases now met with on tea gardens of Assam
are probably of this nature.
Among the various other factors in the production of anæmia,
malarial fevers are perhaps the commonest and most important.
When I was examining two hundred healthy coolies for enlarge
-ment of the spleen and liver on a garden during the rainy
season, I also made a note of the amount of fever from which they
had suffered, and found that the great majority of them had had
fever at some time or other within the previous year, while a
quarter of them had some enlargement of the spleen, although this
was usually very slight. From an examination of the blood of
apparently healthy men in the Nowgong jail, I also found that those
who had suffered from even one week's fever within the last two
years, had distinctly poorer blood than those who had none or less
Anæmia of coolies.
ix
than this amount, so that it is evident that even a slight attack of
fever has a material effect in causing anæmia. It is evident then
that if all coolies who suffer from it to any degree, and especially if it
is of frequent occurrence, could be given a tonic containing arsenic
and iron for a week or two, but more especially the former, because
in the case of anæmia due to malarial fever there is plenty of iron in
an organic form in the liver, etc., but arsenic is required to increase
the formation of new red corpuscles, than I am convinced a very
potent cause of anæmia would be largely removed.
It is not necessary to discuss such common causes of anæmia as
venereal disease and dysentery, while all tea garden practitioners are
fully aware of the important part that the accidents and complications
of childbirth play in the production of the condition among women.
There is one other factor which, I am sure, plays a very important
part in the production of anæmia of coolies, to which sufficient atten
-tion is not paid, and that is the question of diet. It is not the quan
-tity or the quality of the diet that is at fault, for these are well
looked after, but it is not always borne in mind that the first principle
of dietetics is that a proper proportion of each of the primary food
-stuffs is necessary if the diet is to sustain the body in a healthy state.
Now these primary foods are of three classes: firstly, the proteid
or nitrogenous, which will include the albuminous constituents of
flesh, and the nitrogen containing portions of the cereals in which
latter class they are contained in very different proportions in
different grains, being in largest quantity in dal (over 20 per cent.)
and wheat (13.5 per cent.), and least in rice (7 per cent.); secondly, the
carbonaceous substances, such as the starches and sugars, which
form the great bulk of such cereals as rice (78 per cent.) and wheat
(68 per cent.); and thirdly, the fats, which are represented by oils,
butter, and ghee, and are only present in very small quantity in
most of the cereals. If any one of these is deficient in quantity, then
the diet will not be physiologically correct. Again, it is quite possible
to give enough rice to supply all the nitrogenous material that is
necessary; but in order to do so, it would be necessary to give three
times as much as would be required to supply the necessary amount
of the carbonaceous element, which would be a great waste. For
practical purposes, the problem may be still more simplified, as it has
been laid down that in a proper diet there should be one part of
nitrogen to every fifteen of carbon, and if the necessity of a certain
quantity of fatty food be also borne in mind, this will be a good
x Appendix No. I.
rule to work on. Now there is no fear of the amount of carbon
falling short in an Indian diet, in which rice, which contains so much
of it, figures so largely, but I am inclined to think that the amount of
nitrogen often falls short of the necessary amount in the diet on
which tea garden coolies often feed themselves. When it is
also mentioned that it has been found that a deficiency of nitrogen
alone in a diet is sufficient in itself to cause a marked form of anæmia,
the importance of this question will be at once seen. To give
an example which illustrates very forcibly this factor. Some few
years ago anæmia was very prevalent in the Japanese navy under
the name of beri-beri. (The term beri-beri, however, is a misnomer
when applied to anaemic conditions, as true beri-beri is nervous
disease, which is common in the Straits Settlements, and is also seen
in Chinese people in Calcutta, but has never been met with in Assam,
and in which there is no anæmia whatever. The sooner therefore the
use of the term in Assam is dropped altogether, the better it will be, as
it is only a cause of confusion.) Various remedies, both hygienic and
medicinal, were tried in order to reduce the sick- rate, but without
material improvement, until it was found that there was only one
part of nitrogen to 22 of carbon in the diet in use, instead of
1 t o 1 5 . T h i s w a s t h e n r e m e d i e d f i r s t b y t h e u s e o f m e a t a n d e g g s ,
etc., but subsequently it was found that all that was wanted was the
substitution of a certain quantity of barley (containing 11.5 per cent.
of albuminoids) instead of a certain quantity of rice, as the former
contains considerably more nitrogen than the latter. This was done in
the year 1884, but I do not know in what month of the year the change
was effected. The result was as follows: in the years 1881 to 1883,
that is, before the change, the sick-rate per thousand from this cause
had been respectively 205, 404, and 231. In 1884, it was 127, and in
1895, the first year in which the new diet was in force throughout,
the sick-rate was 6 per thousand; in 1886, it was 0.35, and in the next
two years it was nil. These figures speak for themselves, and similar
results have been obtained in the Singapore Jail by Dr. Rowell, by a
reduction of the quantity of rice and an increase of the dal ; but in
this case I am not sure how many of his cases were of the anæmic
type and how many were nervous or true beri-beri. I had hoped
to have been able to have worked out the nitrogenous value of the
diets of coolies on a series of gardens, but time has not permitted of
my doing this, so I must be content to call attention here to the point,
and hope it may be taken up by some of those who have many coolies
Anæmia of coolies.
xi
under their care suffering from anæmic conditions, as I am convinced
that if the consumption of a proper proportion of nitrogenous foods,
such as dal, could be ensured in the case of all coolies in Assam, a
great step would have been taken towards the reduction of the great
loss in life and labour from anæmia of coolies.
In this connection the great prevalence of anæmia among North-
West and Central Provinces wheat-eating coolies is of considerable
interest, for, as already mentioned, they suffer so much from this
disease, that many managers will not employ them at all. Now Dr.
DeRenzy pointed out, when he was Sanitary Commissioner of Assam
some years ago, that coolies from these provinces had just as
high a death-rate, and sometimes even a higher one, in the plantations
of the West Indies, as they still have in Assam, until compulsory
dieting for two years was enforced by Government. From that time
their death-rate fell until it reached only 2 or 3 per cent. It is
also a commonly-held opinion in Assam that the North-West coolies
suffer owing to their great love of saving every pice they can, even
to the extent of underfeeding themselves. This is certainly true inas
-far as they will live on the cheaper rice, rather than incur the much
greater expense of obtaining the higher-priced and more nitrogenous
grains to which they have always been accustomed. But we know
that the Bengali will subsist and keep his health on a diet which
consists nearly entirely of rice, and the quantity that he consumes is
extraordinary. This means that he is eating a much larger quantity
of carbonaceous food elements than his system requires, in order to
obtain sufficient of the nitrogenous food elements to keep him in
health, and, although this is a physiologically wasteful method of feed
-ing, yet he is accustomed to it, and can in this way supply all his
wants. When, however, he gets any illness, such as fever, etc., which
will prevent his digesting these enormous masses of rice, he very
rapidly runs down, which shows that he has not much stamina. The
wheat-eating coolie, on the other hand, is not accustomed to consum
-ing such great quantities of food owing to the amount of wheat and
dal that he eats, taking the place of a much larger quantity of rice,
and so when he suddenly finds himself in a country where wheat can
only be obtained at a prohibitively dear price, then he has to fall back
on eating a larger bulk of rice, which he is scarcely able to hold in
his stomach, and can only digest with great difficulty. This throws
an extra strain on his digestive powers to which he only too often
succumbs. He is now unable to get sufficient nitrogen out of his
b
xii Appendix No. I.
diet, and soon becomes anæmic, and unless he is caught early and fed
up in an "hotel system," he goes from bad to worse. In fact, I
believe it would pay any garden which employs a large number of
this class of coolies, to feed them on the "hotel system" for at least
the first six months, or better still until after the first rainy season is
past. This is I know done in some few cases, but it might with
advantage be carried out much more extensively. In one or two
cases in which I have seen this done, the cost of the diet was deducted
from the pay of the coolie with his consent, and the balance was
ample to supply him with the little comforts which he loves, and both
parties were greatly benefited by the arrangement.
The following is a good example of anæmia, which was largely, is
not entirely, due to bad feeding:—A coolie woman, aged 19, from the
Assam-Bengal Railway, was admitted to the Nowgong dispensary
during the rainy season of 1896, suffering from marked anæmia and
dropsy of the feet and face.
The history of her illness was that she got on all right until her
father died, after which she lived with another coolie girl, and,
according to her story, she only received about one rupee a month
from the contractor, and was consequently unable to feed herself
properly. She soon became ill, and as she did not improve, she left
the works and begged her way some 40 miles into Nowgong, living on
what she could pick up on the way. On her admission she was fairly
well nourished, but very anæmic, her feet and legs were swollen,
and her face was puffy and had been swollen under the eyes shortly
before. Bowels somewhat loose. She had not suffered from fever.
Liver and spleen normal. Conjunctiva of a dead-white colour. She
thus presented all the signs of anæmia due to anchylostomiasis, and
was given thymol. The motions that were passed during the next
twenty-four hours were washed and examined by myself, but no
anchylostoma were present. On examining her blood the following
results were obtained:—Hæmoglobin II per cent., red corpuscles
1,260,000 per cubic millimetre; white 3,250, or I to 384 red; sp. gr.
1.030; hæmoglobin value .43. If these figures be compared with
those given in the table on page 95 as typical of kála-ázar and
anchylostomiasis, respectively, it will be seen that it differs from
both, although it resembles that due to anchylostomiasis, except
in the comparatively high hæmoglobin value, that is, the propor
- t i o n o f h æ m o g l o b i n i n e a c h r e d c o r p u s c l e o f t h e b l o o d . N o w i t
has been shown that a low hæmoglobin value is characteristic of