NationalLibraryOfScotland/medical-history-of-british-india huggingface dataset:
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Report on Kála-ázar.
in chronic cases. The popular idea is that the disease is contagious,
and the natives have so great a horror of its appearance among them,
that they frequently separate those affected from the other members
of the family or community. Mr. McNaught, the Civil Medical
Officer at Tura, has made some enquiries concerning the disease.
He states that it begins with a high temperature, severe pains in the
head and body, loss of appetite, and other symptoms of a general feb-
rile condition: fever sometimes of an aguish form, and sometimes
fever without remission for many days together. The spleen and
liver enlarge, the skin becomes gradually darkened, and in advanced
cases there is often hæmorrhage from the nose and gums; œdema
of the feet or general dropsy is likewise common, and life
ends by a combination of disordered functions known as malarial
cachexia.
" This does not appear to me any new form of disease; its his-
tory, so far as I can at present gather, shows it to be produced by
intense malarial poisoning. It has been known as it is now among
the people for the past twenty years; and the localities chiefly in
which it prevails, are those which combine all the conditions under
which the most intense forms of malarial disease are produced.
Further investigation is necessary to throw a clear light on this
disease. It is so inimical to life, that large tracts of hill country
are being depopulated in consequence."
In Appendix A to the same report, further particulars are
given, in which the following statements occur:—
" As far back as 1869, the attention of administrative officers in
Assam became directed to a peculiar disorder called kála-ázar, the
ravages of which decimated, and in some instances almost depopu-
lated, numerous districts in the Garo Hills.... The disease is most
intense where the low, densely-wooded Garo Hills join on to the
low-lying Central Assam plain, a position par excellence the most
favourable for malarial developments.... The Garos give definite
accounts of the invasion of their villages by this epidemic at periods
varying from 3 to 30 years previously."
After describing the symptoms in detail he continues
—
" Nearly all the preceding symptoms seem to depend on one other
symptom not yet mentioned. That symptom is an intense anæmia,
which shows itself at an early period, and continues to increase
in intensity as the disease progresses. The above symptoms
History of Kála-ázar.
of intense malarial poisoning gradually culminate in a fatal issue.
This usually results from progressive asthenia in from six months
to three years or more. Recovery is rare."
He then mentions that most of the cases were seen once
only, and that further and continuous observations are neces-
sary, and he concludes:
"At present more cannot be said than that from the cases record-
ed: the opinion has been arrived at that kála-ázar is a cachexia pro-
duced by malarial fever, deriving its peculiar characteristics from the
nature of the region where it prevails, and having a singular tendency
to run rapidly into the cachexial stage."
The above extracts show that the disease was considered
to be a bad form of malarial fever, which had probably
been present for many years, but which at certain times
became epidemic, and almost depopulated districts. The
absence of registration of births and deaths makes it impossible
to fix the precise date of the first increased death-rate in the
Garo Hills, and this accounts for the different number of
years that it is said in the above report to have been present.
The highest death-rate in the selected areas of registration,
which was begun in 1882, was 41 .66 per thousand in
1883.
In 1883, the death-rate increased in the portion of Goal-
para which lies at the foot of the Garo Hills; and Dr. Eteson,
who had succeeded Dr. Clarke as Sanitary Commissioner of
Assam, writes:
" It will simplify the measures of relief, and the medical treatment
also, if it is accepted, once for all, that kála-ázar is a marsh ague in its
causation, intensified through chronic lapses into a blood taint, which
passes into anæmia and organic congestions; and that it is only
especially fatal, because the sick Garos are left uncared for, un-
nourished, and exposed to continued relapses."
Relief work was started in the affected districts this year
under the superintendence of Dr. Dobson, who reported at
length on the disease in 1884. His conclusions were
—
" That kála-ázar is no new disease, but only a local name for
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Report on Kála-ázar.
malarial fever and its consequences; that it is essentially chronic in its
nature, originating in ordinary fever and continued by relapses; that
its most noticeable and constant complication is hypertrophy of the
spleen; that darkening of the skin is not at all common; and
that there is not a particle of evidence that kála-ázar is contagious."
Dr. Eteson entirely supported these views. It is also
worth noting that out of 4,919 cases, which were treated by
the relief parties, 4,191 were recorded as for fever or enlarged
spleen, two-thirds of them coming under the latter heading,
and only one case was returned as anæmia; and that even at
this early date it was noted that
—
" The area of the epidemic is extending, counterbalanced by the
fact that it is now absent where it had been severe."
In 1885-86, there is nothing of importance recorded,
except the steady spread of the disease. In 1887, a decrease
of the disease was noted in the terai portion of South Goal-
para, which had been attacked in 1883. In this year also
attention was first drawn to the anchylostoma as the cause
of the so-called " beri-beri" or anæmia of coolies, which had
long been prevalent on many of the tea gardens of, more
especially, the upper parts of the Brahmaputra Valley. Refer-
ring to Dr. Kynsey's pamphlet on this disease as met with
in Ceylon, Dr. Eteson writes:
" There seems little doubt but that the disease described in it
and called beri-beri, is essentially the same as that commonly called
anæmia and dropsy in Assam, often prevalent and very fatal in
the immigrant class. ... Hitherto it has been attributed to malarial
cachexia, and associated with bad drainage, exposure, and climatic
influences. But a careful post-mortem enquiry has demonstrated the
presence of an intestinal parasite, the anchylostomum duodenale,
in all those examined, and in numbers corresponding to the severity
of the symptoms during life."
After stating that water is the probable vehicle of infec
tion, he continues that Dr. Ruddock, of Messa, Nowgong,
" by the administration of thymol in thirty-grain doses, had
almost invariably succeeded in discharging the dead parasite
in hundreds, followed by a rapid restoration to health, the
History of Kála-ázar.
natural colour of the blood, and re-established nutrition";
and he adds
—
" It would be interesting to prosecute this discovery in the direc-
tion of kála-ázar, or the ague cake of Goalpara; but I fear that is
purely malarious."
In 1888, Dr. Costello, who had succeeded Dr. Eteson,
records that there had been a considerable decrease in the
mortality from fevers in the Goalpara district; and, after de-
scribing the very malarious character of this and the Kamrup
districts, he adds
—
" There can be no cause for wonder that one type should be so
pronounced and of so marked a character, as well as often fatal, as
to have been thought to be a distinct disease—I mean kála-ázar, so
common still in the Garo Hills tract and in the parts of Kamrup men-
tioned above. The opinions of the best Civil Surgeons of the prov-
ince, as well as of my predecessor—an officer of great experience—
was, and is, that this apparently peculiar form of fever is nothing
more than a very aggravated, and often neglected, malarious fever,
and also that its so-called distinctive features, such as anæmia, en-
largement of the spleen and liver, with dropsy, diarrhœa, etc., are
merely ordinary results of unusually severe and neglected malarious
fever. No proof of its contagiousness has been given, and the same
medicines, especially quinine, which are found of use in ordinary
malarial fever, are equally useful in kála-ázar, as far as the extent to
which the disease has reached, either from its original intensity or
neglect, will allow."
He appends reports by Surgeon-Major Borah, recently
Civil Surgeon of Kamrup, and by Dr. Gupta, of the Garo
Hills, who both agreed that kála-ázar is only a bad form of
malarial fever. He, however, concludes by stating that he
has applied for a specialist to enquire into the subject. Thus
we see that up to this date every medical man, who had had
any experience of the disease, considered it to be an intense
form of malaria, which was, however, not contagious. The
whole difficulty was in explaining its great fatality, and more
still the slow, but certain, way in which it spread year by year
up the valley. The anchylostomum duodenale had also been
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Report on Kála-ázar.
shown, chiefly by Dr. Ruddock, to be the cause of the
disease known on tea gardens as anæmia of coolies, or beri-
beri. At this period Dr. Giles was appointed to enquire
" and report on the cause or causes of kála-ázar and beri-
beri of Ceylon," and he began work at Gauhati at the end
of November 1889.
A preliminary Note by Dr. Giles was published in May 1890
in the Assam Sanitary Report for 1889, and his final report
in October of the same year. As his results were entirely
opposed to the former views of the disease, it will be necessary
to briefly give them here, as far as possible in his own words,
in order to prevent any possibility of misrepresentation. For-
tunately, this can be done in a comparatively small space, as
he expresses them very clearly in both his preliminary and
complete reports.
In his full report he describes his work in Gauhati as
follows :
" There were five or six in-patients in the dispensary suffering
from kála-ázar, as well as a daily casual attendance of out-patients
suffering from the disease, and the first step was clearly to make a
careful examination of the cases at my disposal. The greater num-
ber certainly presented more or less the prominent symptoms of
malarial poisoning, but it was equally apparent that, in by far the
larger proportion, the malarial symptoms were quite inadequate to
account for the gravity of the mischief. On casually enquiring the
history of a case, the patient would generally say that it had com-
menced with "fever," and he had it off and on for months. On a
more and more close interrogation, however, so as to distinguish true
ague from other maladies, it generally came out that there had been
comparatively little true fever, and that what the patient really meant
was merely that he had been feeling ill for a long time. There is, of
course, nothing new in this, because everywhere in India, nearly all
disease is ascribed by natives to " fever, " and it is only by the most
patient enquiries as to the exact symptoms actually experienced that
one can get any other history for nine diseases out of ten. Then
again, most of the cases had more or less enlargement of the spleen,
many of them exhibiting a regular ague cake ; but when we remember
History of Kála-ázar.
how rare it is in post-mortem examinations to find an Indian with a
spleen of normal weight, it will readily be seen that too much import-
ance should not be attached to a symptom which is well nigh
universal, and is by no means incompatible with fair general
health."
Later on, page 50 of his report, he quotes Dr. Dobson as
having found 21 out of 42 children, in a village in the Goalpara
district, to have enlarged spleens, although apparently healthy ;
and he continues
"This accords with my own experience in the Chaygaon district,
where I examined the spleens of a large number of people reputedly
healthy. The proportion was about the same ; but unfortunately I
have lost the slip on which the notes were made. If then half the
reputedly healthy population show more or less splenic enlargement,
is it surprising that it should be found also in kála-ázar ? The re-
verse would indeed be astonishing; and in the face of such a fact it
is obviously absurd to attach any pathogromonic importance to the
symptom in connection with the etiology of kála-asar."
Returning to page 11of his report, he writes :
" Now the cases in the dispensary, though in a terrible state of
cachexia, gave no other evidence of malarial poisoning than a very
variable amount of splenic enlargement. The temperature charts,
far from forming the well-known malarial trace, exhibited, as their
most marked character, a subnormal temperature, indicative of a
profound depression of the vital forces. ... I have observed the
temperature as low as 94° F., and this in cases by no means actually
dying. A temperature of 95° rising to 96° in the afternoon was often
persistent for several days together : such low temperatures are
almost unknown, except in the case of profound traumatic shock or
in articulo mortis, and are certainly unknown to persist for any
length of time in any other disease than anchylostomiasis. This and
the profound anæmia were the most marked characteristics of the
disease with which I had to deal. Putting aside cases of ordinary
sickness of all sorts, which were freely brought me as kála-ázar,
this aæmia was the one constant symptom. As has been repeatedly
noted by previous observers of kála-ázar, it is the earliest symptom
to appear, and its intensity advances pari passu with the disease.
Its characteristics easily distinguish it from the anæmia which ac-
companies malarial cachexia. In the latter, anæmia is a late and
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Report on Kála-ázar.
secondary symptom, whereas here it appears from the first, and
nearly all the other symptoms are merely its results. Then, again
in the anæmia of malarial cachexia, specially when accompanied by
enlarged spleen and consequent venous and portal obstruction, the
conjunctiva, although deficient in blood, is nearly always of a dirty
yellow tint, often accompanied by distinct icterus. The absolute
dead white, rather bluish than yellow, coloration met with in the
larger proportion of
ká
la-ázar cases, is never met with in uncompli-
cated malaria. There is something peculiarly pathogromonic about
this appearance of the conjunctiva, which, once thoroughly appreciated,
is not easily forgotten."
He continues by stating, that up to this time he had no
idea what might be the cause of the symptoms observed, and,
while waiting for a post-mortem, he "inoculated a considerable
series of tubes of nutrient jelly with the blood of several
patients. With the exception of a few tubes which developed
accidental colonies of well-known mildews, etc., such as will
occur in any series of such observations, these experiments
gave entirely negative results," showing, together with the
absence of the least sign of paralytic symptoms, that kála-ázar
had no connection with the endemic palsy described by
Pekelharing under the name of " beri-beri." He then
continues:
"After about ten days, the death of one of the in-patients enabled
me to make an autopsy. The examination showed that the immediate
cause of death was an exacerbation of a chronic state of dysentery
from which she had suffered during the whole time she had been
under observation. The other changes were œdema and ascites,
excessive anæmia of all the tissues, and an obviously thin and
watery condition of the blood. In the duodenum and upper part
of the jejunum were a number of anchylostomes. In this case then
the primary cause of death was plainly enough anchylostomiasis, and
this led me to examine the dejecta of my other patients, and in every
instance enormous numbers of the ova of the parasite were found.
A rough estimate was made of the numbers passed in a few cases
by diluting a known weight of fæces, and counting the number of
ova in a small weighed portion of the diluted material, with the
result of showing that the number passed daily must often exceed
History of Kála-ázar.
a million. Other post-mortems followed, and proved incontestibly
that, whatever kála-ázar might be elsewhere, the disease so called in
Gauhati was undoubtedly anchylostomiasis."
Having thus satisfied himself as to the nature of the disease
in Gauhati, he made excursions to villages near and made
examinations of the fæcal matter found near the houses, with
the result that
—
" By examining specimens taken at hap-hazard, it was often found
that in badly stricken villages three specimens out of every four would
contain the ova of the parasite (anchylostomum). Further, it was
found that the severity of the outbreak and the proportion of speci-
mens showing ova, was generally proportionate."
He continues
—
" After some stay in the kála-ázar districts, I proceeded to
Upper Assam, and visited the tea-growing districts, where anchylos-
tomiasis has been shown to be so prevalent under the name of beri-
beri. Nothing here struck me so strongly as the absolute identity of
the clinical pictures presented by these cases of acknowledged anchy-
lostomiasis with those I had just been seeing so much of under the
name of kála-ázar."
With regard to treatment, he writes on page 14 of his
report:
"Nothing that has hitherto been tried has had any effect on
kála-ázar, and even thymol is, as a rule, of no use, because cases
seldom, if ever, come to us sufficiently early to be relieved of the
parasites before they have inflicted fatal damage on the system."
And on page 104, he urges the importance of early diagno
-
sis and treatment; and, after remarking that he had at first
hoped that the expulsion of the parasites would be sufficient
to initiate a cure to be completed by proper dieting, he
continues:
" This
a priori notion would doubtless have proved correct
enough if the patients had retained the power of assimilation;
but a further experience of the disease has demonstrated the fact
that the mere loss of nutritive matter required for the support of
the parasites, is a small and quite unimportant factor in the causation
of the fatal symptoms produced by them. Various calculations have
been made as to the amount of blood actually withdrawn by the
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Report on kála ázar.
parasites, and these, though differing pretty widely, agree in making
the amount too small to be likely to do more than seriously weaken
an adult. The real damage is mainly caused by the destruction
of the digestive powers. A large share in the causation of this
diminished power of assimilation, is probably to be accounted for by
the constant recurrence of great numbers of small traumatic lesions
of the mucous membrane. Should these lesions include boring and
temporary encystment, the matter is more easily understood ; but the
bites themselves, in spite of their small area, can account for much."
In the clinical section of his report, he gives abstracts from
the notes of cases recorded by several of the Civil Surgeons
of Assam, to each of which he appends his own opinion as to
the correct diagnosis in view of his discoveries, and concludes
with full notes of two cases seen by himself. One of these
latter, and, as far as can be judged, the other also, are simple,
uncomplicated cases of anchylostomiasis. Out of the thirty
cases he quotes, twenty were from notes by Dr. Dobson,
who, in the Assam Sanitary Report for 1891, very truly
remarks :
" With these extracts of the cases reported by me, and which Dr.
Giles has undertaken to diagnose, I find that such cases as are anæmic
are invariably returned by him as anchylostomiasis, unless it is that
the state of the conjunctivæ is said to be yellow, in which case it is
malarial, Surely it is going too far to practically say it is only
anchylostomiasis w hen there is anæmia. On reading over the diagno-
sis of these cases, as arrived at by Surgeon Giles, anæmia would seem
to be a symptom hardly ever met with in any other disease."
Dr. Giles gives several other arguments in favour of his
view of the disease, which must be mentioned. Thus, in
Section 3h e g i v e s f i g u r e s t o p r o v e t h a t t h e h i g h e s t m o r t a l i t y
occurs in the smallest villages, and that several members of
one family are frequently attacked before other families in the
same place become infected, which, together with the popular
belief to the same effect, leads him to conclude that " the
distribution of kála-ázar is that of a communicable disease."
Again, in discussing the spread of the affection, he points out
that isolated villages may escape in a remarkable manner,
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History of Kála-ázar .
and that it has taken seven years to spread less than 100 miles,
while on page 29 he writes:
" It is a noticeable fact that once the disease has made its appear-
ance in a district, it never leaves it, the weekly returns of the pre-
valence of the disease showing it to be present to day in every part
of the country where it has been hitherto reported."
This was true of whole districts, such as the Garo Hills
or Goalpara at the time it was written, but Dr. Giles seems
to have overlooked the remarks quoted from some of the
Assam sanitary reports earlier in this section, to the effect
that the disease had died out of certain localities which had
previously severely suffered from it. He also makes a strong
point of the fact that no Europeans had suffered from the
disease, and remarks that, although their numbers are small,
yet " their escape would be indeed remarkable if malarial
influences were abroad sufficient to account for the terrible
ravages of kála-ázar "; while, on the other hand, they would
not be at all likely to suffer from such a disease as anchylos
tomiasis, because "it is only among such Europeans whose
habits assimilate them to the semi-civilised inhabitants of
Assam that anchylostomiasis has ever spread." With regard
to its being malarial, he writes:
" Again, if kála-ázar be but malarial cachexia intensified by the
proximity of uncleared jungle, the habits of the people, and so forth,
it is clearly incumbent on the advocates of this theory to show that
these conditions and habits have been intensified in affected villages
coincidently with the outbreak of the disease; but, in point of fact, no
one pretends that any such change has taken place."
A very clear summary of these views is given on pages
65 and 66 of his report, which must be quoted:
"In the absence, then, of any intelligible cause for intensification
of the well-known malariousness of the affected districts, it seems as
great a mistake to attach any importance, in the production of the
increased mortality, to such cases of malarial cachexia as one meets
with, as to the cases of dysentery, pneumonia, and spinal caries.
Personally, I have not found cases of uncomplicated malarial cachexia
at all commoner than I have in certain parts, for example, of the
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