NationalLibraryOfScotland/medical-history-of-british-india huggingface dataset:
1 N
Nature of kála-ázar. 123
Nowgong in the years before either of them were attacked
by kála-ázar. Now I have adduced evidence in Section III
to show that anchylostomiasis is so rare among the inhabit-
ants of the Nowgong district, apart from the coolies working
on the tea gardens and railway, that I have not been able
to find a single case which would stand the test of the blood
examination, and the administration of thymol and counting
the worms passed, so that it may at least be said that this
parasite is certainly not more common in the Nowgong
district, if it is as common as it is in Tezpur, Sibsagar,
and Dibrugarh, while the fever prevalence differs very slightly,
apart from kála-ázar in the two cases. Yet we have Now-
gong literally decimated by the disease, while the medical
practitioners of Upper Assam (Sibsagar and Dibrugarh),
some of whom had been over twenty years in the country,
unanimously testify, after being shown cases of kála-ázar,
that "the disease appears to be entirely unknown in Upper
Assam above Nowgong, and differs in every particular from
anchylostomiasis," while Tezpur (excluding the Mangaldai
subdivision) was until quite recently free from the epidemic,
although I know from personal observation that there is plenty
of anchylostomiasis on some of the gardens there, and it used to
be more malarious than Nowgong. Thus we find that one district
in which anchylostomiasis is very rare among the indigenous
inhabitants, who, be it remarked, suffer most severely from kála-
ázar, and in which, previous to the advent of the epidemic,
suffered little, if at all more, from malarious fevers than those
of Upper Assam, is more than decimated by the disease,
while the latter in which both these diseases are present in
much the same, if not in greater, degree than they are in
Nowgong, have so far entirely escaped it.
The same thing is true of individual places in the affected
area. For example, a certain out-garden in the Nowgong
district is in daily communication with the head garden, dis-
tanced five miles, and both have suffered from kála-ázar
for several years past. Yet another independent garden, only
R 2
124
Report on Kála-ázar.
three-quarters of a mile from the affected out-garden, but with
which it is not in direct communication, had remained quite
free from the disease up to the time of my visit. Yet on this
very garden, which escaped the disease, I found more anchylos
-tomiasis (verified by thymol and blood examinations) than on
any other garden of the district that I visited, and there was
plenty of malaria on both the attacked and escaping gardens,
for they are both situated just under low hills. The two
supposed contributing diseases were present in this case in a
most marked degree, yet not a single case of kála-ázar had
arisen.
One other conclusive point may be mentioned here. Dr.
Sandwith has shown that anchylostomiasis is as common in
Egypt to-day as it was in the time of Griesinger (1851), and
gives historical evidence to prove that "there is no reason for
thinking they were not equally common in the days of the
eighteenth dynasty (over three thousand years ago). Dr.
Thornhill, of Ceylon, whose writings on the subject of anchy
-lostomiasis are well known (but who labours under the dis
- a d v a n t a g e , w h e n w r i t i n g o nk
á l a - á z a r ,
o f n e v e r h a v i n g s e e n
a case of this latter disease), in an answer to some questions
that I put to him, for which I am much indebted, says that, in
the absence of improved sanitation or migration of the inhabit
- a n t s , a n c h y l o s t o m i a s i s w o u l d n e v e r d i e o u t o f a p l a c e i n t o
which it had once been introduced, but would always be
increasing in the numbers it attacked, and be slowly spreading
to other places; and that if kála-ázar dies out of the places
it has previously affected in the absence of such conditions
as he mentions, then it cannot be due to anchylostomiasis.
In this opinion I quite agree with him. I have carefully
enquired into the facts; and, as will be shown in Section VI, it
is quite certain that the disease does die out nearly, if not quite
completely, in the absence of either improved sanitation or
migration of the inhabitants. One quotation on the point
only need be given here. Mr. Heath, formerly Deputy Com
- m i s s i o n e r o f t h e G a r o H i l l s , a f t e r t o u r i n g t h r o u g h t h e c o u n t r y
Nature of Kála-ázar.
125
which suffered, perhaps, more severely than any other part of
Assam, namely, the foot of the Garo Hills, writes in 1887:
"Between Parakhasma and Singimari" (some 70 miles)"it would
be hard to find one single case of the real illness."
And again:
"Elsewhere along the border it has cleared away the weak and
sickly, leaving the strong, but having done this, has cleared itself
away."
Here it is evident that there has been no migration, and
I can vouch for the fact of there having been no appreciable
improvement of sanitation. But enough has been written.
on the negative side of the question, which but for the unfor
-tunate errors of the earlier investigation need scarcely have
been touched upon, while the facts already given in this re
-port speak more eloquently in disproof of Dr. Giles' conclu
-sions than anything I can write on the subject.
I s t h e d i s e a s e s o n l y a n
i n t e n s e f o r m o f m a l a r i a l
f e v e r ? The way in which the affection has spread steadily up
the valley, without there being any evi-
the districts attacked, and the opinion,
which is nearly universal in Assam, that it is in some
way or other a communicable disease, have always been the
great difficulties in accepting this, the original, and always the
most commonly-held, view of the disease. However, in
accordance with my plan of work, I have looked to clinical
and pathological evidence to prove whether malaria is only
one factor in the production of the disease, as it is now
universally believed to be, or whether it forms the entire
pathological entity, and have regarded the question of its
communicability or otherwise as an entirely distinct problem,
which requires to be studied in a different way .altogether.
Leaving then out of the question for the present, whether it
is possible to explain the origin and spread of the disease on
the hypothesis of its being simply malarial, let us see what
light the clinical and pathological facts already given throw
on the problem. In passing, I would point out that much of
126
Report on Kàla-àzar.
the confusion which has surrounded this subject, has been
due to those who held that the disease was entirely malarial,
saying that, therefore, it could not be infectious, while those
who held it was infectious, said it could not therefore be
entirely malarial, while, as is usually the case, both sides
were partly right and partly wrong.
As the clinical and pathological sections of this report
consist almost entirely of a description of malaria, it will
only be necessary here to enumerate the main points which
have been established in them. Firstly, fever accompanied
by enlargement of the liver and spleen is the one marked and
constant feature of the disease. The type of the fever is
indistinguishable from ordinary malarial fever to such a degree,
that in the early stages, it is quite impossible by the most
minute work to tell whether one is dealing with a case of
ordinary malarial fever or the commencement of kàla-àzar, and
it is only when signs of malarial cachexia begin to develope,
and it is found that ordinary doses of quinine will not suffice
to control the fever, that a positive diagnosis is possible, In
the later stages, the disease presents only the usual symptoms
of malarial cachexia, and even then, individually considered, it
is impossible to distinguish them from chronic malaria, as can
be seen at a glance by a comparison of the photographs of
kàla-àzar cases opposite pages 33 and 57, with those of
ordinary malarial cachexia as seen in Sylhet, where there is no
kàla-àzar, opposite page 29. How then can kàla-àsar be
diagnosed. Only by the extreme rapidity, a very few months,
in which marked cachexia is produced, and by the occurrence
of several cases of the disease in the same village or household,
where previously such a type of fever was unknown, for it is a
remarkable fact, which is well illustrated by the result of the
Kokilamukh meeting of planters' doctors already quoted,
that, except perhaps under the hills in the southern portions of
Goalpara and Kamrup, this type of relapsing malarial fever
running into cachexia, is very rare in the Assam Valley. This
point will be further illustrated in Section VII, when it will
Nature of kála-ázar.
be shown that the villagers of Assam readily recognise the
fever of kála-ázar immediately it occurs among them as some
- t h i n g q u i t e d i f f e r e n t f r o m a n y t h i n g t h e y h a v e p r e v i o u s l y
suffered from. The other great distinguishing feature, besides
the intensity and frequency of relapse, is the extraordinary
tendency it has to run in families, which at Once suggests the
possibility of the fever being communicable from one person to
another, and this feature and its intensity are the only points
which I have met with in which kála-ázar differs from
ordinary malarial fever.
To continue, the anæmia of kála-ázar has been shown
to be of precisely the same type as has been met with in
malarial fever in other parts of India, and is totally differ
-ent from that of anchylostomiasis, and it is also propor
- t i o n a t e t o t h e f e v e r , a n d l e s s e n s a t o n c e i f t h i s i s a b s e n t
for two or three weeks, which could not be the case if it were
produced by anchylostoma. More conclusive still is the
fact that in all early cases that were examined, and which
subsequently developed into typical cases of the disease, the
malarial organisms were easily demonstrated by an examina
-tion of the fixed specimens of the blood under an oil-emersion
lines of a microscope, and these did not differ from those
found by me in simple cases of malarial fever, both in Assam
and in Ranchi in Bengal, while similar organisms were also found
in all stages of the disease. Further, a series of sections of
the liver, spleen, and kidneys showed the constant presence of
marked pigmentation, such as has always been considered an
absolutely constant change in chronic malaria in all parts of
the world, and which to many people is better evidence of
the malarial nature of a disease even than the discovery of
t he pl asmodi um mal ari æ i t sel f, whi l e t he excess of i ron i n t he
liver, as shown by the analysis done in Calcutta, confirmed
this point. Once more, the constant and marked enlarge
-ment of the spleen, and almost as frequently of the liver also,
has never been found in any chronic fever besides malaria, and
all the other symptoms and pathological changes met with in
127
128
Report on Kála-ázar.
the disease are also found in chronic malaria in other parts of
India and elsewhere. Lastly, the seasonal distribution of the
disease, as will be shown more fully in the next section, and as
can be very well seen in the charts there given, is precisely
that of the ordinary malarial fever of the province, with the
exception that it is somewhat more extended one in accord
- a n c e w i t h t h e g r e a t e r i n t e n s i t y o f t h e f e v e r . T h e d i s e a s e
then is a very intense form of malarial fever.
After what has been written above, it is scarcely necessary
to discuss this view. It is, however,
Is kála-ázar a new and
hitherto undescribed dis-
open for any one to say that there is
ease?
something in the disease in addition to
.malaria, which I have not discovered, but which accounts for the
spread of the affection. Whether any will continue to hold this
view will depend on the success or otherwise of the evidence
and argument given in the latter part of this report, to prove
that the origin and spread of the epidemic can be satisfac
- torily explained on the hypothesis that the disease is entirely
malarial. It may, however, be remarked that, apart from the
inherent improbability of the supposition that some other
disease is so engrafted on the malarial element as to give it
the power of infection, for which purpose it must necessarily
be a constant feature, and yet does not reveal its presence
by producing one single symptom in addition to those caused
by malaria, I know of no such combination of diseases in any
analogous epidemic affection.
(129)
SECTION VI.
THE GENERAL COURSE AND DISTRIBUTION OF THE
EPIDEMIC.
In the history of kála-ázar, which comprises the first section
of this report, a general outline of the course of the epidemic
has been given. This it will be necessary to amplify in some
particulars in the present one, in which will be discussed the
ravages which the disease has caused, its general course in a
district, its present distribution, and the directions of its recent
spread.
Much could be written on this heading, and many quota
-tions could be given, showing how the
epidemic has depopulated whole tracts
of the terai portions of Goalpara, Kamrup, and Nowgong
districts, and has so greatly reduced the population of
other parts as to make it impossible for some of the tea
gardens of Kamrup to get more than a very small part of the
labour they want from local sources, although, before the
epidemic affected the district, they had more applicants than
they could find employment for; how certain tracts of the
Nowgong district, which a few years ago were covered by fields
of mustard and populous villages, now only support a few
Nepalese people who graze their cattle on the once-cultivated
land; how the very name kála-ázar strikes such terror into
the heart of natives of the affected parts, that whole villages
have deserted their homes in order to escape from the disease,
and have even migrated to a different district, and wretched
sufferers from the fever have been turned out of the villages
in which they lived and bandied about from one to another,
no one being willing to admit them for fear of catching the
fever themselves, while parts of villages have cut off all
communication with their relations in a neighbouring portion of
the same village for fear of infection; how the Garos were
commonly credited in former days with taking affected persons
The ravages of the
diseases.
S
130
Report on Kála-ázar.
out into the jungle, and after making them unconscious with
drink, setting fire to the temporary huts in which they were
placed, and so burning them to death, while, even in the present
day, I have myself seen a patient placed in a grass hut in the
middle of the dry-up rice-fields, a little way outside the village,
as the people would not allow her to come inside it, even to
the house of her own father; but still more eloquent in
testifying to the fearful results of the epidemic on any
district over which it passes like a fell scourge, are the follow
-ing figures showing the actual decrease in the inhabitants of
the affected parts between one census and another, and the
area of land that has fallen out of cultivation directly owing
to this decrease of the population.
When the figures of the census of 1881 are compared
with those of 1891, it appears that in the Goalpara district,
which felt the full force of the epidemic within the decade
between the two censuses
—
"The indigenous population shows a decrease of 20,449, or 4.8 per
cent., of which 8,344, or 1.9 per cent., is attributable to an increase
in the number of emigrants to other districts, and the remainder to
the very heavy mortality due to the spread of kála-ázar. The actual
loss is much greater, as will appear if we consider the changes in
the population of each subdivision separately. In the sadr division
(on the north side of the river), where the disease has not spread to
any great extent, and there has, moreover, been a considerable
immigration from the neighbouring Bengal districts, there has been
an increase of 35,771 persons, or 19.36 per cent. In the Goalpara
subdivision (on the south side of the river), on the other hand, the
ravages of kála-ázar are chiefly responsible for a reduction of 29,699
persons, or 18.08 per cent."
Again, with regard to Kamrup it is recorded that, allowing
for the increase in the number of emigrants
—
"The falling off in the indigenous population is reduced to 10,245,
or 1.6 per cent., which is wholly owing to the mortality from
kála-ázar. Between the years 1872 and 1881, the number of the
inhabitants rose from 561, 681 to 644, 960—an advance of 14.83
per cent.—and, although this was in part due to the more thorough
counting of the people which was effected in 1881, there is no doubt
General course and distribution of the epidemic.
131
that there was a substantial increase of population during these nine
years. The only cause which has prevented further growth is the
mortality from this disease, but for which it is not unreasonable to
suppose that a further advance of at least 10 per cent. would have
been recorded. On this assumption the population now recorded is
less by 75,000 persons than it would have been had there been no
deaths from kála-ázar."
Here again, the figures for the north and south banks
must be taken separately in order to see the full effect of the
disease, thus—
"The north bank has been comparatively free from kála-ázar,
and its population has been slowly growing. (Increase in ten years
2.04 per cent.). The south bank, on other hand, which contains the
affected tracts, shows a very heavy decrease. Its population in 1891
was 172,125, and this has now fallen to 151,802, or by nearly 12 per
cent. If figures were available to compare the district born in this
track in 1881 with those now returned, the decrease would be greater
still, as this part of the district contains the town of Gauhati, and
almost all the tea gardens, so that its immigrant population is
larger than in 1881, and its district born population less by the same
amount."
It must be remembered, too, that this district was still
suffering to some extent from the epidemic at the time of the
1891 census, so that the full loss of population is not shown
in these figures. In Nowgong, on the other hand, which
had not been appreciably affected up to the time of the
1891 census, there was, allowing for emigration from the
district, a natural increase of 32,518, or 10.4 per cent.
The next census will tell a very different tale with regard
to this district, and it will not be until its results are known
that any correct estimation of the degree to which it has
suffered from the epidemic during the last seven years,
will be possible. The same remark applies to the Mangaldai
subdivision of Darrang.
There was no regular census in the whole of the Garo
Hills district in 1881, but a census was taken of the plains
portion, and in the hills an estimate was formed by applying
to the ascertained number of houses the average population
S 2
132
Report on Kála-ázar.
per house found in certain test villages, and it is recorded
that —
"Including persons born in the Garo Hills, but censused else-
where, the natural growth of the population amounts to 12.21 per cent.
in the ten years, or 1.14 per cent. per annum. As the district has
in parts suffered very severely from kála-ázar, it is improbable that
this increase is altogether real. It seems likely that that part at least
is due to the population having been slightly under-estimated in
1881."
Allowing for this under-estimation, it is still evident that
there must have been some increase in the population during
this decade, which seems to show that some of the loss that
must have occurred during the prevalence of the epidemic, had
been made up during the later eighties, when the epide-
mic had largely, if not entirely, died out, and this affords
hope of a similar phenomena being seen in the next census
returns for the Goalpara and Kamrup districts.
For the following figures, showing the extent to which
land has fallen out of cultivation in the affected districts, I have
to thank Mr. Gait, the Secretary to the Chief Commis-
sioner of Assam, to whom I am indebted for much inform-
ation with regard to this and other particulars.
In the Gauhati subdivision, the number of bighas of land
under cultivation in 1887-88 was 379,377, but three years
later, in 1890-91, this number had fallen by 10,946, but in
1894-95, about half of this loss had been regained. It must
be remembered that all of the country comprised in this
subdivision did not suffer from the disease, and in particular
mauzas the loss was proportionately much greater. During
the same years there had been a smaller decrease in the
Earpeta subdivision, which was much less affected by the
epidemic. In the affected parts of Mangaldai, namely, the
Pathorighat and Mangaldai tahsils, there has been a steady
decrease year by year from 208,096 bighas under cultivation
in 1891-92 to 182,149 in 1896-97, or a loss of 25,952 bighas,
which is just about one-quarter of the total, although there is
still a great demand for land in this densely-populated portion
I F
Chart spewing monthly Death-rate from Fevers year by year in the Goalpara, Kumrup, and Nowgong Districts.
Li t ho. . S. I. O. , Cal cut t a.
Reg. No. 159, Surg. Capt . & L. Rogers on speci al dul y. Assam. —Aug. 97. —600.
General course and distribution of the epidemic. 133
of the district. In Nowgong, the whole of which has been
affected by the epidemic, although it is not over there yet,
there has been a decrease of 29,477 bighas of land under
cultivation since 1891-92, in which year there were 150,465
bighas rented, while the average of the years 1890—92
were 23,024 more than that the average of the years 1894-96—
a most notable decrease which corresponds with a loss of
revenue of about one-fifth of the total. These figures speak
for themselves, and when it is remembered that, unless there
are an unusually large number of deaths in a village, the
survivors take up the land of those who have died, then some
faint idea can be formed as to the amount of mortality and
sickness such a falling-off in land cultivation and of revenue
must indicate.
From the figures given above, it will be evident that some
very marked effect on the death-rate of the affected districts
ought to be noticeable during the epidemic years in any
district. Such is indeed found to be the case when the
number of deaths returned under the heading of "Fever"
(including those returned as kála-ázar during the last five
years since this has been made into a separate heading), is
examined.
The chart opposite this page shows the monthly death-
rate from fever and kála-ázar combined during the years it
was prevalent in the Goalpara, Kamrup, and Nowgong dis
- t r i c t s , o n e u n d e r t h e o t h e r i n t h e o r d e r n a m e d f r o m a b o v e
downwards. It was only in September 1891 that the
deaths from kála-ázar were separately returned, and since that
date in the Nowgong district there has been a steady decline in
the number of deaths returned under the head of Fever, as
those returned as kála-ázar, has increased. It is evident then
that many deaths from ordinary fevers have been returned
under the head of Kála-ázar, so that it would be incorrect to
take the latter figures as showing the increased death-rate
from the epidemic disease. By combining both together and
comparing the total with the former death-rate from ordinary