NationalLibraryOfScotland/medical-history-of-british-india huggingface dataset:
( 137 )
and, if necessary, treated before being allowed to mix with, the
others. At the same time, here also I must repeat that such
measures can only be considered as adjuncts to the adoption of
proper sanitary precautions, and, apart from these, can never
be expected to really stamp out the disease, as such measures
infallibly must do, if only carried out with sufficient efficiency.
The measures I have to recommend may therefore be
stated as follows—
A.—With respect to " Jcdla-azdr " in villages :—
1st.—The adoption and enforcement of some simple
system of conservancy.
2nd.—Migration from infected sites when practicable ;
the disinfection of infected sites, by the measures
above described, when migration is impossible.
3rd.—The improvement of water-supply where this is at
present unsatisfactory.
4th.—The clearing and drainage of ground included in
village sites wherever practicable.
B.—With respect to " be ri beri " in tea-gardens :—
1st.—The enforcement of proper conservanc} 7 ", preferably
on the dry-earth system.
2nd.—The removal of lines to a new site wherever the
disease has been very prevalent.
3rd.—Where this is impracticable or undesirable, the
disinfection of the site by the means above
indicated.
4th.—The adoption of raised " chang " huts, such as are
customary in Burmese villages, whenever new
huts are constructed.
5th.—The entire prohibition of small enclosures round
or near huts.
6th.—The prohibition of the keeping of cattle within the
inhabited limits of coolie-lines, and the provision
of suitable separate enclosures for the purpose.
7th.—The provision of a proper water-supply in cases
when this is at present unsatisfactory; the points
to be aimed at being—
(a) That the well or other source of supply should
be some little distance from all habitations.
(b) That if a well, it should be completely protected
by a locked cover, so that water can only
be got by pumping.
L
( 138 )
(c) That it should be carried by means of pipes to
tanks above level of soil placed convenient-
ly among the dwellings.
(d) In certain cases, e.g., when river-water is the
source of supply, it will be necessary, and
in all cases it is desirable, to filter it by
some apparatus on the ascension principle.
8th.—The provision of a proper supply of green vege-
tables, either by cultivation and sale to the
coolies at cost prices, or by the provision of
patches of ground somewhat on the English
village " allotment ground " system.
( 139 ;
XI.—ANCHYLOSTOMIASIS IN TEA-GARDENS.
That the sickliness among labourers imported from India
into Assam, has, almost from the first, been a matter of
serious concern to the Local Government is a matter which may
be gathered from successive emigration reports. It is of
course only of late years that the dependence of the up-to-then
inexplicable mortality has been traced to anchylostomiasis,
but the connection is now so firmly established that it would be
quite superfluous for me to enter upon any attempt to prove
what is already admitted.
Practically speaking, where any garden remains for any
length of time on the " black list," it may be taken as certain
that the cases that make up the excess over the normal
mortality will be cases of anchylostomiasis. Of course, an
outbreak of cholera may put a garden on the list for any given
year, but an establishment will be singularly unlucky if such
an accident should occur on two or more successive years, and
putting aside cholera, the cause of relegation to the " black
list " will be found to be anchylostomiasis in more than nine
cases out of ten. Practically speaking, there are no statistics
available that can give even an approximation to the amount
of mortality that should be credited to the cause. Of late
years, an attempt has been made to arrive at it by introducing
separate headings for aneemia and dropsy* in the mortality
returns of unhealthy gardens, but the results, so far, are quite
valueless, as often not a single case will be recorded in a whole
year from all the unhealthy gardens of an entire district,
and that in parts of the country where all European medi-
cal officers are perfectly agreed that the disease is extremely
rife. The fact is that, with but few exceptions, the persons
responsible for the diagnoses of the cases from which the
statistics are compiled are the native doctors of the tea-
estates. I njay have been unfortunate in those I met, but, speak-
ing only of those I have seen, I can only say that I have never-
met with a body of men more grossly ignorant of their work.*f*
In spite of the fact that anchylostomiasis has now for several
years been known to be the main cause of mortality among tea-
garden labourers, very few seemed to have the least power of
recognizing cases, and their entire diagnostic powers seemed to
* Sanitary Commissioner's Circular No. 14S., dated the 10th May
1889, directed the term " anchylostomiasis " only to be used in all garden
returns.
t See Eule 122 under the Inland Emigration Act, I. of 1882.
L2
( 140 )
consist in the ability to make a lame translation into English
medical terms of what the patient thought was the matter with
him. To instance one case, met with among many, I may
mention a black-listed tea-garden that I visited in company with
Dr. Bannerji in the Sibsagar district. On visiting the hospital,
we asked the native doctor whether he had any cases of anemia,
and he replied that they never had had any. In spite of this, there
were sitting in the hospital verandah some half-a-dozen
advanced cases of anchylostomiasis, which had been entered in
the register as fever, dysentery, bronchitis, spleen, and so on,
according to the coolie's notion of what was the matter with
him. I then asked them to assemble all they could of the
working hands, and some 60 were got together. Of these, a
full third were found to be suffering from the earlier stages of
the disease. Dr. Bannerji was at great pains to try and explain
to the man the symptoms and treatment of such cases, but,
from the expression of his face, I am strongly inclined .to doubt
if he was left a penny the wiser, the fact being that the idea
of finding out a patient's disease for oneself was something
entirely outside his notions of medical practice.
However, while these special statistics are so collected as
to be quite worthless, those of the general mortality upon tea-
gardens are probably more accurate than anything else of the
kind in India. Whatever may be the proportion of the total
that is due to anchylostomiasis, it is certainly so large that any
increase or diminution in the disease would exert a marked
influence on the total mortality ; and, judging from the re-
turns of the last eight years, there can have been but little
change in the yearly number of victims, but what change
there has been is for the worse; the past year showing a
higher total mortality than any of the eight except 1884 ; and,
when it is remembered that this increase has taken place in spite
of much general sanitary improvement, but little doubt can
arise as to the steady increase of this disease, which, as we have
seen, is untouched by any sanitary measures save one, which
has been left neglected. The actual total mortality ranges from
36-2 in 1889 to" 43-2 in 1884, and last year stood at 41'8. Con-
sidering that this' mortality includes not only that of anchy-
lostomiasis, but also of heavy annual outbreaks of cholera, the
general conditions of coolie life on the gardens cannot be
considered at all unfavourable, and if we could but stamp out
anchylostomiasis, would midoubtedty compare well with those
of any part of India. It is curious in looking over byegone
reports to see that opinion has passed through exactly the same
( 147 )
custom, which, is permitted even on some of the best-managed
gardens, is the close association of cattle and human
beings. The large number of coolies who own cows is of
course an excellent sign of their well-being, but this is no
reason for permitting cattle and human beings to share one
dwelling.
In the better cases the coolie builds a small lean-to shed
against his hut, but everyone knows the filthy state in which
natives keep their cattle-sheds, and, in a damp climate like
Assam, the foul drainage from the cattle-shed cannot fail to soak
through into the sub-soil beneath the hut. It is to be doubted if
this arrangement be not actually worse than the actual associa-
tion of cattle and men, as it is probable that, in the latter case, a
certain amount of daily cleaning would be attempted. Provi-
sion should be, of course, made for the housing of the cattle,
but it should be in a quite distinct enclosure, near to, but not
in, the lines, all the cattle being kept together very much in
the fashion of the cattle "kraals" in use among the Zulus.
Care should be also taken that this enclosure should be placed
lower in the drainage line of the land, and, if possible, to
leeward of the coolie-lines with the prevailing wind. The
ground so occupied soon becomes richly manured, and the
Zulus utilize this circumstance by periodically moving their
kraals, and sowing the ground with maize and vegetables, of
which they thus obtain immense crops. This practice has, too
the additional advantage of thoroughly purifying the ground,
though it is needless to remark that this is a consideration
which in no way influences the Zulus, for though their habits
are, in point of fact, far less unsanitary than those of Indians,
this is due rather to the accident of circumstances than to
any particular desire or liking for cleanliness. Perhaps the
greatest fault in the huts of all the coolie-lines I have met with,
and I cannot recall a single exception, is that they are never
provided with any plinth worthy of the name, an omission of
a most fatal character in a country like Assam, where the
raising of dwellings above the damp soil is a matter of the
first importance. Of course, the provision of raised plinths
would be a matter of considerable expense, especially as, in
such a climate as this, nothing short of three or four feet can
be considered adequate. Another disadvantage is that the
necessary excavations would leave the ground honey-combed
with depressions, which would certainly become receptacles for
rubbish, and in the rains would" be always full of filthy stag-
nant water. The whole plan then, of any of the huts I have
Table showing the regular increase in the number of unhealthy gardens and their rate of mortality per thousand
during the past five years.
Name of district.
Kamrup
Darrang
Sibsagar
Lakhimpur
Nowgong
Cachar
Sylhet
1885.
3
9
5
3
3
1
...
104.6
101-2
91-1
116-0
81-5
...
...
188
222
109-6
171
103-9
...
...
1886.
Number of unhealthy gardens.
Nil.
8
15
14
4
10
13
Nil.
106-8
87-9
97-5
91-6
163-4
196-2
229-8
96-1
i
84-8 229-7
95-4 289
1887.
Nil.
10
10
15
2
7
5
Nil.
106-8
109-2
88-0
76-7
91-6
93-
228-9
285
115-7
77
114-0
117-2
1888.
2
12
21
17
2
7
4
81.5
82-4
105-8
93-1
136
107-3
85-0
86-3
111-8
193-6
138-4
187-8
301
101-4
1889.
1
21
33
27
6
12
10
96-0
685
94-3
61-4
87-1
92-8
95-1
96-0
322-3
214-8
170-2
193-9
157-4
181-4
(142)
( 143 )
Serious as it is, the mortality gives but a faint idea of the
prevalence of the disease, the number actually affected being
always largely in excess of the sick list. As an example, I may
instance a special examination of Ohunsali garden, near Gauhati,
which was made on August 31st, 1890, with the following
results :—
The estate finds employment, as a rule, for over four
hundred hands, out of which, at the time of my visit, only 121
(53 men and 68 women) were contract labourers, the remain-
der being obtained in the local labour market. The whole of
the contract labourers alike, working or on the sick list, were
carefully examined for the symptoms of anchylostomiasis, en-
largement of the spleen, and malarial cachexia, with the follow-
ing results. Out of the total number, 65 presented more or
less marked symptoms of anchylostomiasis, or 53'7 per cent.
These cases may be classified as below :—
Table showing prevalence of Anchylostomiasis among Contract
Coolies at Chunsali tea-garden.
Sex.
Males
Females
Total of both sexes
3
3
6
14
12
26
17
16
33
34
31
65
Those entered under the heading " Unmistakeable symp-
toms " include cases where there could be no reasonable doubt
as to the diagnosis, but which would still be, in all probability,
amenable to treatment with thymol. On the other hand, those
included under that of " Advanced symptoms " are cases where
the prognosis would be bad, whatever treatment might be
adopted.
With respect to the prevalence of enlargement of the
spleen, a greater or less degree of it was present in 45
out of the total number, i.e., 37*2 per cent.
( 144 )
These instances of splenic enlargement were classified as
follows:—
Table showing number of cases of splenic enlargement among Contract
Labourers on Ghunsali Tea-garden.
Sex.
Males
Females
Total of both sexes
10
10
20
(•T
3
10
5
10
15
22
23
45
No relationship whatever could be made out between the
prevalence of the two conditions. Some of the worst instances
of anchylostomiasis had no splenic enlargement whatever,
while, on the other hand, the case presenting perhaps the
largest spleen of any showed no signs of anchylo&tomiasis, and
laughed heartily at me when I asked him how long he had
been ill, saying that he did not know that he was ill.
There were five cases of malarial cachexia either present-
ing no signs of anchylostomiasis, or but slightly so compli-
cated, and some of the cases included under this head had but
slight splenic enlargement. The degree of splenic enlargement
was estimated by the native doctor while I was examining for
anchylostomiasis, and the figures can therefore be in no way
influenced by my own preconceived notions as to its absolute
unimportance in the causation of Mla-azdr. It is, however,
at least certain that he has not underestimated the prevalence
of splenic enlargement, as the list includes many cases of
abdominal enlargements from ascites consequent on advanced
anchylostomiasis, where, personally, I could find 110 physical
evidence of enlargement of the spleen.
The coolie-lines at Ghunsali are placed on an excellent site,
the natural drainage of which is perfect. The well-water is
bad, but the manager states they have been disused for a long
time, and that nothing is used but Brahmaputra water, and
I have little doubt this is broadly the case, as the river is
nearer the greater part of the coolie-lines than the wells are,
and probably only the few coolies who live nearer the wells
than the river use the former. No systematic examination of
( 145 )
the non-contract labourers was practicable, but I saw enough to
convince me that they are at least as seriously affected as the
contract hands, and in exactly the same way.
The instance of this garden is interesting, as it shows how
entirely what is called kdla-azdr depends on anchylostomiasis,
the Civil Surgeon remarking that he could see no difference*
between this outbreak and those of kdla-azdr in villages. Now,
in this connection, the above facts speak too strongly for
themselves to need any comment; but it is worthy of note that
the proportion of cases affected with enlargement of the spleen
corresponds closely with Dr. Dobson's observations on its
prevalence among reputedly healthy children.
The irregular and apparently capricious distribution of the
centres of epidemic intensity in any given neighbourhood also
exactly recall what was found to be the case on the distribution
of kdla-azdr, and is an additional proof of the identity of the
maladies known under the two names. It will be observed too,
that, in both instances, while the severity of the disease is
rapidly increasing in severity in localized centres, and while
the number of the centres is steadily increasing, the increased
mortality, when absorbed into the data of a whole district, is
not sufficient to make any very distinct mark on its vital statis-
tics, and this is exactly what might be expected in the case of
anchylostomiasis, which, from the nature of the mechanism of
its spread, must essentially be always a disease characterized
by very localized centres of great intensity. It is also clear
that, in spite of thymol, and of "Such attempts at sanitary
improvement as have been made up to the present, the number
of such centres is steadily increasing, and that their severity
shows no sign of diminishing. I will now describe what I
observed of the physical surroundings of the garden labourers
as far as sanitary conditions are concerned.
(a) Housing.—There is no condition that varies more
widely than this does in different gardens. In some cases, espe-
cially on the larger concerns, a great deal of money has been
spent in providing comfortable habitations, while in others
the " lines " consist of the most wretched hovels imaginable.
On the whole, however, in this, as indeed in other sanitary
matters, there is a praiseworthy eagerness on the part of the
planting community to do everything in their power for the
welfare of their coolies; but great mistakes are often made,
and money spent to no purpose, simply through an ignorancẽ
Vide page 17.
( 146 )
of sanitary matters, in which, be it said, they are by no means
peculiar. As a rule, the " lines " consist of thatched huts with
wattle-and-daub walls ; but in some cases corrugated-iron has,
with great advantage, been substituted as a roofing material,
and more permanent materials have been employed as a por-
tion of the walls.
About the best pattern of huts I met with consisted of two
rooms, the gables and two pillars placed midway along the sides,
consisting of rubble in mortar masonry, while the sides were
filled in with wattle and daub work (ekra). The roof was of
corrugated iron, and was prolonged beyond the gable containing
the door, so as to form a sort of verandah. One drawback
of its construction was an absence of ventilation. The lateral
walls were necessarily too low to make ventilation openings
in them tolerable to the inmates, while the solid nature of
the gables prevented the upper part of these being utilized
for the purpose. Again the advantage of the superior weather-
tightness of the door gable was neutralized by its protection
by the verandah. On this account it would be better, and
probably in the end cheaper, to make the lateral walls of
masonry and the gables of ekra, in which case the peak of the
gables can be left unplastered as to afford sufficient ventilation
without annoyance to the inmates, a plan which I have seen
in use in many gardens where the huts are walled entirely
with ekra. If then, the roof were prolonged at both ends, the
whole of the mud-plastered portion of the building would be
protected from the weather, and a very durable hut would
result. Another fault was that the back room had no exterior
door, and so was intolerably dark and stuffy. "Whatever plan
be adopted, it is perfectly certain that no room should ever be
constructed without a door communicating with the open air.
The best point about the hut was the provision of a verandah,
which is a matter of great importance in a climate like Assam.
Coolies should, however, be never permitted to wall these in, as
they are very fond of doing, as, if this be allowed, they are
nothing better than a hindrance to ventilation. In many cases
I found small garden compounds, rudely fenced in, attached to
the huts. They rarely, however, showed any signs of cultiva-
tion, and the untidy hedges were nothing better than conve-
nient hiding-places for rubbish and filth of all sorts. The
encouragement of the cultivation of fresh vegetables is, no
doubt, a most important matter; but I strongly doubt if it
realty is encouraged in this way, as scarcely any of these little
patches showed signs of cultivation. Another most pernicious
( 147 )
custom, which, is permitted even on some of the best-managed
gardens, is the close association of cattle and human
beings. The large number of coolies who own cows is of
course an excellent sign of their well-being, but this is no
reason for permitting cattle and human beings to share one
dwelling.
In the better cases the coolie builds a small lean-to shed
against his hut, but everyone knows the filthy state in which
natives keep their cattle-sheds, and, in a damp climate like
Assam, the foul drainage from the cattle-shed cannot fail to soak
through into the sub-soil beneath the hut. It is to be doubted if
this arrangement be not actually worse than the actual associa-
tion of cattle and men, as it is probable that, in the latter case, a
certain amount of daily cleaning would be attempted. Provi-
sion should be, of course, made for the housing of the cattle,
but it should be in a quite distinct enclosure, near to, but not
in, the lines, all the cattle being kept together very much in
the fashion of the cattle "kraals" in use among the Zulus.
Care should be also taken that this enclosure should be placed
lower in the drainage line of the land, and, if possible, to
leeward of the coolie-lines with the prevailing wind. The
ground so occupied soon becomes richly manured, and the
Zulus utilize this circumstance by periodically moving their
kraals, and sowing the ground with maize and vegetables, of
which they thus obtain immense crops. This practice has, too
the additional advantage of thoroughly purifying the ground,
though it is needless to remark that this is a consideration
which in no way influences the Zulus, for though their habits
are, in point of fact, far less unsanitary than those of Indians,
this is due rather to the accident of circumstances than to
any particular desire or liking for cleanliness. Perhaps the
greatest fault in the huts of all the coolie-lines I have met with,
and I cannot recall a single exception, is that they are never
provided with any plinth worthy of the name, an omission of
a most fatal character in a country like Assam, where the
raising of dwellings above the damp soil is a matter of the
first importance. Of course, the provision of raised plinths
would be a matter of considerable expense, especially as, in
such a climate as this, nothing short of three or four feet can
be considered adequate. Another disadvantage is that the
necessary excavations would leave the ground honey-combed
with depressions, which would certainly become receptacles for
rubbish, and in the rains would be always full of filthy stag-
nant water. The whole plan then, of any of the huts I have