NationalLibraryOfScotland/medical-history-of-british-india huggingface dataset:
Report on Kála-ázar.
Central Provinces and Punjab. What I have, however, found is that
whenever a village is seriously affected with kála-ázar, the larger
proportion of serious illness will be found to consist of anchylosto-
miasis. That a very large proportion of the cases will be found to
be complicated with enlargement of the spleen is quite beside the
question, for, as we have seen, this condition nearly as often compli-
cates apparent health. Malaria doubtless accounts for as much sick-
ness and death as it always has, and that, we know well, is no small
amount; but it is entirely inadequate to serve as the efficient cause of
the terrible death-rate of kála-ázar stricken villages, and the true
cause of this will be found to be neither more nor less than anchy-
lostomiasis. Of course, it is perfectly intelligible that a man brought
low by anchylostomiasis should fall a ready victim to malarial influ-
ences. In the closely analogous case of famine we know this to be
the case, but it is to the shortness of food, and not to malaria, that we
ascribe the high death-rate of periods of famine, in spite of the fact
that many poor, half-starved wretches might have survived but for
attacks of fever and enlargement of the spleen. Conversely, a man
already the subject of malarial cachexia, will die much more rapidly
from anchylostomiasis than an originally healthy subject.
" As will be seen, I am far from asserting that any and every case
that will be produced as kála-ázar, is necessarily anchylostomiasis,
or that cases of malarial cachexia are otherwise than very common,
for such cases are very common now, always have been, and it will be
a long time ere they cease to be so. All I wish to convey is that the
increased mortality is due to the anchylostomiasis, and to no other
cause, and hence the answer to the question propounded at the
commencement of this section, must be that if we take kála-ázar to
be anything brought as such, kála-ázar may be anything; but if we
confine ourselves to the cause of the present pestilence, the reply is
that it is anchylostomiasis."
Again he writes in his preliminary report:
" I t w i l l b e r e a d i l y s e e n h o w t h o r o u g h l y t h i s e x p l a n a t i o n s o l v e s
all the difficulties that have hitherto surrounded this obscure disease.
Using the term in its broad sense of communicability, there is no
disease that can fairly be said to be more infectious than anchylosto-
miasis, always assuming the absence of proper measures of conserv-
ancy and the co-existence of suitable climatic conditions. That
these conditions are most efficiently present in Assam, is already
1 2
H i s t o r y o f K á l a - á s a r .
abundantly shown by the terrible mortality which, under the name of
beri-beri, the same disease has caused amongst the labourers on the
tea gardens."
I have, I think, quoted enough to show that granting the
correctness of the statements on which Dr. Giles' views are
based, the fact that he found anæmia to be the one constant
feature of the disease, while fever and enlargement of the
spleen were accidental complications, and finding the anchylos-
toma constantly present, which had been proved to cause
anæmia in every part of the world where they had been found,
he could not have come to any other conclusion than that
recorded. He spent the rest of the year, over which his
investigation lasted, in a study of the life history of the an-
chylostomum, which resulted in his coming to the conclusion
that the disease is spread much more by earth and dust
getting into food, etc., than by water, and consequently
recommending conservancy improvements as the main way
to combat the spread of the disease.
The reception of Dr. Giles' report, and the subsequent re-
searches of the Civil Medical Officers of the province, which
have led to the re-investigation of the subject, only remain to
be considered.
In the report for 1890, Dr. Costello writes :
" My conclusion now is that Dr. Giles' views as to the cause of
kála-ázar are quite true, it and beri-beri being due to an
c h y l o s t o m i a s i s , t h e a p p a r e n t d i f f e r e n c e b e i n g d u e t ok
á l a - á z a r
being
fre-
quently complicated by malarious fever and its results ; as in the dis-
tricts of the Lower Assam Valley, the inhabitants are much more
subject to malarious causes than those in the districts in the northern
section of that valley."
He recommended a trial of the conservancy measures
advised by Dr. Giles, and also directed systematic clinical and
microscopic observations to be made in the affected districts
for one year. As a result of this, two very valuable reports by
Drs. Dobson and Campbell appeared in the . 1891 Sanitary
Report, a summary of which will be given here. Dr. Neil
13
Report on Kála-ázar.
Campbell gives notes of 83 cases, Which he classes in three
divisions, thus—(1) Malarial cachexia, 7 cases, in which
no ova were found in the stools, or no anchylostoma after the
administration of thymol. (2) Anchylostomiasis, 15 cases,
(3) Anchylostomiasis plus malaria, 65 cases, which he sub-
divides into—(1) where the malarial complication is slight, 15
cases, and (2) where it is of a serious nature, 50 cases. The
anchylostoma were noted either as simply being found in
about two-thirds of the cases, or as having been present in
" numbers " in about one-third of them, while in two they
were found in large numbers. The finding of ova in the
stools, or of any of the parasites after the use of thymol, is
taken as a proof of the presence of anchylostomiasis. He
sums up his results as follows:
. " I believe that in kála-ázar the starting or exciting cause is infec-
tion by dochmius duodenalis, hence the number attacked and the
rapidity with which it spreads; that it spreads in various ways by
air getting into food, etc., but also by contamination of water, though
Dr. Giles denies the latter. After the patient has become infected
with the dochmius, he, as parasites are added by fresh infections,
develops a lower vitality, and is liable to other diseases; and as
Goalpara and Kamrup are notoriously malarial districts, the anchylos-
tomiasis is complicated by malarial cachexia. Hence, I believe,
k á l a - á z a r ,
as so called by the natives of Lower Assam, is in 75 per
cent. anchylostomiasis plus malarial cachexia, and in the remaining
25 per cent. either anchylostomiasis, pure and simple (in 10 to 15
per cent.), or pure malarial cachexia (in 5 to 10 per cent.)."
Moreover, in discussing the purely malarial class, he says:
"This division might be omitted, as it is not really kála-ázar, but
for the fact that the patients, their friends, and their native doctors
call it so."
It will be seen that his view is substantially a strong
confirmation of the results arrived at by Dr. Giles, and if it
be granted that the presence of the anchylostoma or their
ova is evidence of anchylostomiasis, that is, of a diseased
condition brought about by this parasite, the opinion expressed
1 4
History of Kála-ázar.
is a perfectly logical one. In the report of 1894, however,
that is, after the publication of Dr. Dobson's discoveries, to be
immediately described, Dr. Campbell writes:
" I believe it to be a severe form of paludal fever, complicated in
70 to 80 per cent. of the cases with anchylostomiasis."
Coming to Dr. Dobson's work, it may be summed up in a
few words. In the course of some four years he examined
over 1,000 persons for the presence of anchylostoma, and in
all, except those examined in his first year's work, 1891, he
has recorded the exact number of the various intestinal para-
sites passed after the administration of thymol, with the
exception of thread worms. I find an analysis of his tables
shows that out of 797 healthy people, no less than 620, or 77.78
per cent., harboured anchylostoma in numbers ranging from
1 to 230. Of the total number, 651 were coolies imported
from all parts of India, and 80 . 18 per cent. of them carried
this parasite into Assam with them; while 146 were healthy
men in some of the jails of Assam (and so the great majority
of them were either inhabitants of Assam, or had been resident
in this province for some time), and 67.12 per cent, had an-
chylostoma in them. These figures point to the conclusion
that the worm in question is more commonly present in natives
of Bengal, Chota Nagpur, the Central and North-Western
Provinces, and other parts from which coolies are imported,
than it is in those of Assam. In 116 cases of kála-ázar, Dr.
Dobson found the worms in exactly 75 per cent., and in 212
cases of other illnesses he found them in 73 . 20 per cent.
Moreover, taking the cases in which the exact numbers present
are stated, they average much the same in the kála-ázar cases
as they do in the healthy natives. It will be at once seen that
these observations are of the utmost importance, as, in the
absence of any figures to show in what numbers the anchylos-
toma were found to be present in the cases of kála-ázar inves-
tigated by Dr. Giles, they throw great doubt on the correct-
ness of the view taken by that observer, that this parasite is
the cause of kála-ázar. In fact, it is not too much to say
15
16
Report on Kála-ázar.
that it is due mainly to these observations, that the question
has been re-opened.
The gradual changes of the views of the medical men in
Assam with regard to kála-ázar during the five years that
elapsed between the publication of Dr. Giles' report and the
determination to have the question re-investigated, can be
best illustrated from the remarks of the successive Sanitary
Commissioners in Assam reports. Thus, in 1891 report
Dr. Costello writes:
"After the most careful enquiry in each of the affected districts
of t he Gar o Hi l l s , Goal par a, Kamr up, and Nowgong, wher e I vi s i t ed,
with the Civil Surgeons, all the notoriously affected centres, my
opinion now is, as regards kála-ázar, that Dr. Giles discovered and
hit the true cause which makes that disease contagious or carriage-
able from place to place and from person to person by infected
persons disseminating the embryoes of the dochmius in the soil
through their fæces, and which is also the main factor of its remark-
able fatality, i.e., that he was the first person to discover and prove
that the dochmius or anchylostomum parasite was an important and
distinctive factor in this disease, and that which completely distin-
guished it from ordinary " malarious " disease. ... However, in com-
paring kála-ázar with anæmia or beri-beri of Ceylon, and in deciding
that they were, in all their main points, essentially the same, Dr.
Giles, in my opinion and in those of the officers most competent to
judge (namely, the Civil Surgeons who had seen most of the disease),
overlooked the very important malarious element in kála-ázar. It is
our opinion that the difference between the two diseases is altogether
and only the result of the effects of intense malarious poisoning, aris-
ing from the topographical peculiarities of the localities made noto-
rious by káta-ázar, which do not exist in anything like the same
intensity in Upper Assam, where the anæmia or beri-beri form of
anchylostomiasis has been known for years to be common, and where
such remarkable and deadly terais, etc,, as exist in Lower Assam,
are rare, or almost absent."
A little further on he writes:
" From Dr. Dobson's report it is clearly Proved that kála-ázar is
not mere anæmia of coolies or beri-beri of Ceylon, but that, on the
contrary, malaria plays a chief part in this disease, and so com-
plicates it as to render it much more fatal and serious."
History of Kála-ázar.
In the 1892 report the same officer, after recording that
the mortality from kála-ázar had much decreased in the
Goalpara and Kamrup districts, while it had increased in the
Nowgong and Mangaldai subdivisions, writes:
" As regards kála-ázar, the further observations, as far as they
have gone, go towards throwing doubt on Dr. Giles' conclusions, and
seem rather to point, as was previously supposed, towards malaria
in some form being the main factor in causing that disease. In fact,
no satisfactory conclusion as regards its cause has, in my present
opinion drawn from the latest evidence at my disposal, been arrived
at, and, except, that Dr. Giles wrote a most interesting life history
of the parasite, and also confirmed our previous views as to beri-beri
of Ceylon (anæmia of coolies) being a form of anchylostomiasis, I can-
not now, with the further light thrown on the subject, see that we have
as yet discovered the undoubted cause of this disease."
He, therefore, applied for the services of a fully competent
pathologist and bacteriologist to re-investigate the subject.
The results of some enquiries from tea garden doctors on
the subject of anæmia of coolies, are also given in this report,
which show that they unanimously attribute the disease
known as anæmia of coolies to anchylostomiasis; but most of
them look on such predisposing causes as malaria, bad
feeding, and other causes of debility as being necessary factors
in its production, in addition to the presence of the parasite,
and regard it as being very uncommon among the indigenous
inhabitants of Assam, who have not worked on tea gardens.
In the 1893 report, Dr. Warburton, who had succeeded
Dr. Costello, after reviewing the symptoms of the disease,
writes:
" It will be seen that many of the symptoms that I have named are
also characteristic signs of malarial poisoning, while others are not
inconsistent with it;" and again "its unequal incidence where
sanitary conditions appear equally bad, the gradual and steady pro
-gress downhill unaffected by treatment, the statement that it is
slowly, but steadily, extending up the valley, seem to point to some-
thing more than malarial cachexia, and that something is, in my opinion,
not the dochmius duodenalis. I have seen cases in Northern
Report on Kála-ázar.
India with symptoms so like those seen in cases of kála-ázar in Now-
gong, that they would most certainly have been returned as such,
had they occurred there, and there is at present in the Golaghat
dispensary a case entered as splenitis, which, if seen at Nowgong,
would be described as a typical case of kála-ázar. Yet this man,
an ex-garden coolie from the neighbourhood, has never been in the
Nowgong district. Locking at all the circumstances connected with
the so-called kála-ázar epidemic, I am convinced that, if malarial
conditions could be completely removed, kála-ázar would cease to
exist."
He, therefore, recommends improved sanitation, rather than
a re-investigation of the disease, as a better way of spending
whatever money might be available.
In the report for 1894, Dr. Stephen, who had succeeded
Dr. Warburton as Sanitary Commissioner of Assam, gives a
very clear summary of the reasons for and against kála-ázar
being a form of malarial fever. In the former list he gives —
(1) the symptoms in the first instance cannot be distinguish-
ed from those of malarial fever; (2) the disease never makes
its appearance except in very malarious places; (3) except
that the liver is much more enlarged in kála-ázar, to the naked
eye pathological changes are the same as in chronic malarial;
(4) persons suffering from kála-ázar and chronic malarial
fevers, are frequently carried off by the same secondary
diseases, viz., dysentery and diarrhœa, and, in the cold-
weather months, pneumonia. On the other hand, the main
differences are:—(1) the distribution and way in which
the disease has spread, is very different from that of malarial
fevers, and (2) several members of one house, or part of a
village, may die of the disease before other families or houses
suffer, while malaria will equally attack all parts of a village
which are in the same sanitary condition; (3) the liver is
more enlarged in kála-ázar; (4) quinine and arsenic seem
to have no effect in advanced cases of kála-ázar, but he
also remarks that quinine is not so useful in cases of chronic
malarial fevers as it is in acute cases of quotidian fever.
18
History of Kála-ázar.
He gives the following summary of the opinions of the
various Civil Surgeons who had seen the disease:
" Surgeon-Major Borah is of the opinion that kála-ázar is some-
.
thing more than malarial cachexia. Surgeon Major Mullane believes
that the disease is nothing more than an aggravated form of malarial
fever. Surgeon-Major Campbell is under the impression that the
disease is malarial fever complicated in 75 to 80 per cent. of the
cases with anchylostomiasis. He, however, is not quite certain if
some other cause does not come into play, as later on in his letter
he states that, were a bacteriologist appointed to investigate the
disease, he might discover it to he due to a micro-organism, differ-
ing from the plasmodium malaria. ... Mr. McNaught believes
that it is a specific disease distinct from malarial fever. The medi-
cal officers of tea gardens, who met at Kokilamukh on the 30th
October 1894, after examining persons suffering from kála-ázar
brought before them by Drs. Price and Lavertine of Nowgong, came
to the conclusion that the disease was distinct from malarial fever,
as they remark that it appears to be entirely unknown in Upper
Assam. All medical officers whom I have consulted, with the ex-
ception of Surgeon-Major Campbell, are of the opinion that the
disease is in no way dependent on anchylostomiasis."
T h e V i e w s o f D r . M a c n a m a r a o n l y r e m a i n t o b e r e c o r d e d
as set forth very succinctly in an appendix to this report.
He writes:
"There can be no doubt that we have some disease in Assam
which appears to be going up the valley of the Brahmaputra.
... There seems to be no record of similar outbreaks in Assam in former
times, but I have known epidemics of what was believed to be
malarial fever in the Surma Valley. I confess my inability to dis-
tinguish kála-ázar from malarial fever by any physical sign or sub-
jective symptom apart from a history of residence and the downward
tendency of its course. I am satisfied the dochmius duodenalis is
not the cause of kála-ázar, because I found abundance of the para-
sites where there was no kála-ázar, and, conversely, kála-ázar in
cases where no parasites were present. I have no evidence that
kála-ázar is contagious. It does, however, appear to spread as
diseases, which are known loosely as contagious, spread."
All the Civil Surgeons above mentioned agreed in recom-
19
D 2
Report on Kála-ázar.
mending that the services of a specialist should be obtained,
who would be able to devote his whole time to investigating the
disease, as they had no time for systematic observations of a
scientific kind. Surgeon-Colonel Stephen gives it as his opinion:
"From what I have seen of the disease, and from what I have
been told of it by those who have had the opportunity of studying
it, I am under the impression that, though allied to malarial fever, it
is probably a separate disease, and as none of the rermedies used
seem to have had any effect in stopping its ravages, and as it is
steadily spreading eastwards up the Assam Valley on both sides of
the river, I would recommend that a specialist be appointed to en-
quire into its cause."
And he suggests either Dr. Hankin, the North-West
Provinces Bacteriologist, or Dr. Haffkine, who was at this
time in Assam carrying out his inoculations against cholera, as
suitable a man for the work.
In the report for 1895, there is nothing new recorded, ex-
cept that the disease was beginning to die out of the Now-
gong district.
Space does not permit of any reference to the views of
those who have written on the subject without any practical
acquaintance with the disease; but enough has been said to
show that, until the time of Dr. Giles' investigation, everyone
who had studied the disease believed it to be malarial in its
nature, although no one could satisfactorily explain its steady
spread up the valley. Dr. Giles' theory furnished an explan-
ation of this difficulty, and was accepted, with the reservation
that he had under-estimated the malarial element, until Dr.
Dobson's laborious researches threw doubt upon it, since
which time the pendulum of the united professional opinion of
the province has swung back again to the belief, that the
essential element of the disease is malarial, while the old
difficulty of its epidemic nature leads some to think that,
either there is some other factor in it besides malaria which
accounts for this feature, or it is an entirely different and
new disease.
2 0
(21)
SECTION II.
THE NATURE OF THE PROBLEM, PLAN OF WORK, AND
COURSE OF THE INVESTIGATION.
THE NATURE OF THE PROBLEM.
From the history of the epidemic, as recorded in the last
section, it will be seen that the problem at the time of the
re-opening of the question, may be stated thus. The disease
might be
—
(1) Anchylostomiasis, pure and simple, or, in the words
of Dr. Giles, " The increased mortality is due to anchylos-
tomiasis, and to no other cause," although he also writes-
" The disease is due to anchylostomiasis acting in people
already worn down by malaria," and says that the only
difference between the disease as met with in the kála ázar
districts in the lower part of the Assam valley, and anchylos-
tomiasis as seen on tea gardens in the upper districts, is
that in the former malarial complications are much more
common.
(2) Malarial fever of a very intense form spreading in
a wave of increased mortality up the valley. This view
necessitates the admission that malaria may, under excep-
tional circumstances, become communicable, which has
always appeared to be an insuperable objection to it.
(3) That it is due to a combination of both anchylosto-
miasis and malaria acting in varying proportions in different
cases, the former factor accounting for the spread, and the
latter for the much greater mortality than is usually the case
in simple anchylostomiasis. This view seems to be that
which is most commonly held outside Assam by nearly all
who have written on he subject without any close personal
acquaintance with the disease. On the other hand, it must
be admitted that of those who have had much experience of
Report on Kála-ázar.
the disease, only one, namely, Dr. Campbell, inclines to this
view, and even he now looks on malaria as the essential part
of the disease, and states that it is corn plicated by anchylos-
tomis in about 73 per cent. of the cases.
(4) That it is a new and distinct disease. The only
advocate of this view that I know of, is Mr. McNaught , of
Nowgong, and it must be admitted that he has had excep-
tional opportunities of seeing the disease. He was, however,
when in the Garo Hills, an equally strong supporter of the
malarial view of the affection, but the steady spread of the
disease has caused him to alter his opinions.
PLAN OF WORK.
Having handed over medical charge of the nth Bengal
Infantry on April 3rd, 1896, work was commenced in Calcutta
on the 6th by a study of the literature of kála-ázar and allied
diseases. Leaving Calcutta on the 16th, two days were spent
at Dhubri, where Dr. Dobson kindly gave me an opportunity of
seeing some coolies examined for anchylostoma. Brief visits
were paid to Gauhati, Shillong, and Tezpur, and my head-
quarters were reached on April 27th at Nowgong. During these
visits, it became a p parent that one of the main causes of the
absence of any very precise knowledge of the disease lay in the
fact that, owing to its chronic nature, Civil Surgeons are unable
t o f o l l o w c a s e s f r o m t h e b e g i n n i n g t o t h e e n d o f t h e a t t a c k s ,
and in fact rarely see them until they have arrived at a late stage,
and then only too often they remain but a few days in hospital.
In order to try and settle the vexed question of the true na-
ture of kála-ázar, the following plan of work was decided on,
and only slight additions to, and modifications of, it have been
found necessary.
(I) A careful clinical study of the disease, the cases
being followed up as long as possible, especial care being
taken to determine the frequency of the presence of anchy
-
2 2