NationalLibraryOfScotland/medical-history-of-british-india huggingface dataset:
Distribution of the disease in relation to its spread. 145
to be affected by the disease, a village about a mile from the
ghát having been attacked during the last rainy season (1896),
while I have also been informed of an outbreak of the disease
in some villages on the Bishnath side of Tezpur between the
two places. I know of no outbreak of the disease to the
east of Bishnath.
Summary of the
broad facts relating to
the spread of the dis
-ease.
The facts given in this section may be
summed up in the following propositions:
(1) The epidemic of the malarial fever, which is known in
Assam under the name of ká la-ázar, shows itself in a district
as a wave of increased mortality returned under the head of
"Fever," which takes two or three years to reach its height,
which is then maintained for another three years, after which it
declines, leaving behind it a decrease both in the population,
the amount of land under cultivation, and the land revenue; to
-gether with tracts of country from which all the inhabitants
have been cleared off. The seasonal distribution of the
disease is that of ordinary malarial fever, only slightly more
extended.
(2) There has been no alteration in either the climatic or
physical condition, or in the sanitary state of the affected
districts to account for the origin or spread of the disease.
(3) The disease spread steadily up the south bank of the
Brahmaputra river, along the grand trunk road, until it
reached Nowgong, where it spread both along the foot of
the hills directly east and also north-east along the grand
trunk road and the thickly-populated banks of the Kulung
and Kopeli rivers, but has been checked by the uninhabited
tracts of jungle stretching east of Silghat and Joklabanda.
(4) The districts on the north bank of the Brahmaputra
river have suffered less severely than those on the south bank,
owing to their being more sparsely populated; but wherever
free inter-communication has existed between groups of villages
on the north bank and the affected tracts on the south side, theU
Report on Kála-ázar.
disease has spread to the north bank, as has been seen in the
case of parts of Goalpara, Barpeta, Mangaldai, Tezpur, and
Bishnath.
(5) Throughout its whole course the extension of the epide
-mic has presented a persistent relationship to lines of communi
- c a t i o n , b o t h o n l a n d a n d i n i t s f r e q u e n t c r o s s i n g o f t h e r i v e r ,
which can only be explained on the supposition that it is spread
by means of human intercourse, and hence is a communicable
disease.
The precise way in which it is carried must be left for
consideration in the next section.
146
(147)
SECTION VII.
ON THE COMMUNICABILITY OF KÁLA-ÁZAR.
We have seen in the last section that the general distribu-
tion of kála-ázar is that of a communicable disease, and that
it always spreads along the lines of traffic or human inter-
course, while it is checked by any tract of uninhabited country
through which there is no road; that it has crossed the
Brahmaputra river on several occasions, always in the lines
of the greatest traffic, and that the way it has gradually
crept up the Assam Valley, cannot be explained on any
local change of the soil or sanitary conditions of the affected
districts, while the natives themselves, and also many of
the Europeans who have come into intimate contact with
the disease, agree in believing that the disease is in some way
communicable from man to man, while this opinion was
confirmed by Dr. Giles as a result of his investigation in
1889-90. It is then of the first importance to try and trace
in what way the disease is transmitted from place to place.
In order to ascertain in what way, if any, its progress can be
checked, for it is evident that its spread cannot be explained
on the ground of its being anchylostomiasis, as this is not the
cause of the affection.
That this has not yet been done, and that there are some
who are still sceptical as to the disease being communicable
at all, is due to the great difficulties in tracing the spread
of an affection, which must be present in any individual case
for a long period, always several weeks, and often two or
three months before it is recognisable from such a universally
present disease as ordinary malarial fever, and from which
it may, individually considered, be absolutely indistinguish-
able throughout its whole course, and sometimes whose very
presence in a village, or even on a tea garden, has not been
recognised until it had produced a great increase in the death-
rate, which may take it at least a year to bring about. When
U 2
148
Report on Kála-ázar.
it is remembered that outbreaks of such diseases as
cholera and plague, which have an incubation of period of
only a few days, and which are so rapidly fatal as to
immediately attract attention, are yet not unfrequently
impossible to trace to their original source, it is not surprising
that it has been found difficult hitherto to conclusively prove
the communicability of Ká la-ázar, although I have met
very few in Assam who were not perfectly convinced that
it is so.
In the course of my earlier travels in Assam, I every now
- a n d - t h e n m e t w i t h i n s t a n c e s i n w h i c h t h e h i s t o r y o f i n f e c t i o n
seemed to be very clear, and which encouraged me to hope
that a systematic inquiry into this part of the subject would
produce interesting and very valuable results. A tour was
accordingly undertaken through certain parts of the Now-
gong, Mangaldai, and Tezpur districts, that is, those which
had most recently been attacked by the epidemic, in order
to test this point, and it may be said at once that I was much
astonished with the frequency with which a clear history of
the introduction of the disease by means of human intercourse
could be obtained, and still more by the remarkable way in
which the villagers very often recognised the first case, which
occurred amongst them, as something quite different from
anything they had previously experienced within the memory
of the oldest. In the great majority of villages, in which
either the headman or a relation of the first case of t he
disease could be questioned, a clear history was obtained.
This will be best illustrated by the narration of a morning's
work, and then instances which illustrate the various ways in
which the disease is spread, and other points of importance,
will be given.
In the course of a five hours' tramp around six villages
A morning's inquiries in near Lunka, in the south-east corner
some affected villages. of the Nowgong district, the following
results were obtained. As far as possible, leading questions
were avoided, and it was generally only necessary, after
Communicability of kála-ázar.
149
ascertaining how long they had suffered from the disease, to
ask how it began, and immediately would come the answer,
that the first case was such and such a man, who had returned
from such and such a village, which was at the time affected
with kála-ázar, suffering from fever, and that the next case
or two were members of his household, after which it had
spread to the others in the village. Notes in short-hand
were taken on the spot in each case.
Village L.
The headman of the village informed me that four years
ago, in March, his son-in-law came to
live in this village from another, four
miles away, which was affected with kála-ázar at that time,
and he had also been in Nowgong town a short time before,
where the disease was also very prevalent. At the date of
his return he was suffering from fever, which had begun
when he was in the neighbouring village. He was the first
to die of kála-azár in this village, and the next case was that
of a man who lived close to him, and who used frequently
to come and sit with him when he was ill. After that it
spread to the others in the village, but the infection of indivi
- d u a l c a s e s w a s n o t k n o w n . T w o - t h i r d s o f t h e p e o p l e o f t h i s
village are said by the headman, who is responsible for the
registration of the deaths, to have died during the epidemic,
but at the present time (December 1896) it is much less,
although I saw several well-marked cases. They were inclined
to very seriously consider my suggestion to remove their
houses to a new site during the cold weather, as they were
convinced that the soil and houses were infected. In one
house in this village seven of the members of the family had
died of the disease, and the other two now have it. They
were also certain that any one who lived in a house in which
other cases of the disease resided, was very likely to get it,
and that it was often spread by orphans, who had lost their
parents of the disease, being taken into other houses, which
had been previously free from it. In this village, out of five
men who took opium regularly before it was attacked by the
Report on Kála-ázar.
disease, four had escaped, and the fifth only got it after seven
of his household had suffered from it. Many of them now took
it, as they were convinced that those who did so, were both
less likely to suffer from it, and also had a better chance of
recovering; and they showed me a boy, who had been given
three grains of the drug a day while he was suffering from kála
- á z a r ,
a n d w h o w a s n o w q u i t e w e l l . I t i s w o r t h y o f n o t e t h a t
this history of an increased consumption of opium since the
appearance of the epidemic, and as a direct result of it, was
obtained in all the villages around here, which are inhabited
by the Hosais—a people who are addicted to the habit; and
on inquiry at the local opium shop, this increased consump
- t i o n w a s c o n f i r m e d .
A man lived for twelve days in a village on the Jumuna
river (only a few miles from here), in which
there was kála-ázar at the time, and got
fever whilst there, and returned with it to this village. He
and his brother, who lived in the same house with him, were
the first to die of the disease in this place, and it afterwards
spread through the village. There have been very few fresh
cases this year, 1895 having been the worst year.
This village was found to be deserted, although a
month previously there were two families
here who had three bad cases of the
disease among them. I subsequently learnt that two of
these had died, and the people had then gone to live in
another village not far off, which had, however, previously
suffered from the epidemic. It is easy to see how disease
might be spread in such a way as this; as, indeed, it often is.
Had suffered from the epidemic for the last five
years; 1895 was the worst year. The
first case was that of a man of this village
(whose name as usual was given), who was a boat-
man. He went to Roha (some 30 miles off) and came
back with fever, of which he died in this village. The
second case was that of a man who used to go and eat in
Village S.
Village H-a.
Village H.
Communicability of kála-ázar.
the house of the first case, and the third and fourth cases
were the wife and son, respectively, of the first case. The
whole of the family of the second sufferer died of the disease.
The first cases occurred during the rainy season. When
nearly all the first infected family had died of the disease,
another brother came to live with one of them, who had
the fever, and this brother also got fever and died of
kála-ázar.
Kála-ázar has been present here for the last five years.
The headman of this village first got fever
in another village, one mile off, where it
was prevalent at that time. This was in the month of
January, and on his return to this village, some of his family
next got the fever, but it was not until the ensuing rainy
season that it spread to others in the village. About 80
persons have died of the disease here.
This village has suffered for three years from kála-
ázar, and about half the people have
died of the disease. The first case
was that of a man who came from Doboka (a large
village, some 15 miles from this place) with fever, and
died in this village of kála-ázar. There was kála-ázar
in Doboka at the time he got fever there. Two others
afterwards died in his house. In the same year, a woman
married a man of this village, and came to live here from a
neighbouring one. Soon after she came, it was noticed
that she had fever, and six months later she died of kála
-ázar, and her husband left the village. It was subsequently
ascertained by the villagers that this woman had lost a husband
of the disease before marrying this man. Here then we have
two separate infected people coming to live in this village
in one year, although it was apparently only through the first
that the disease was spread here. In this village again, out
of ten or eleven, who took opium before the epidemic fever
broke out, none died of the disease, and many more now take
it.
151
Village D-n.
Village G-a.
152
Report on Kála-ázar.
This group of villages is situated in a very out-of-the
way part of the district, and it will be noticed that in some
of them the disease was brought from a distance by persons
coming to live in them after having contracted the fever in
one or other of the larger and earlier infected places, while
others are infected from the neighbouring villages into which
the disease was first introduced from some little distance.
This is the usual way in which the disease travels, and the
very irregular distribution of the affected villages in any
part of a district which is just being invaded by the epidemic,
is thus accounted for. Subsequently, when once the disease
has broken out in a few villages in any place, the frequent
inter-communication between the affected and unaffected
villages ensures all of them being attacked sooner or later,
except in the rare cases where the villagers recognise in
time the infectiousness of the disease, and cut off all com
-munication with those who have got it, and then a part of
a village may escape, although it is present in the rest of the
same village from which it is only separated by two or three
hundred yards of rice-fields. Another common mode of
conveyance of the disease is through the custom, amounting
almost to a religious duty, of the people visiting sick relatives
in the neighbouring villages, which very often means eating
and sleeping with them. Again, I have met with instances in
which the disease was spread by persons who are actually
suffering from it, and who have lost all near relatives on whom
they were dependent, being taken into the houses of other
relations in different and previously unaffected villages. In
these and many other ways the disease, when once it has
been introduced into a district, spreads slowly and surely, but
in a very irregular manner until almost every village suffers.
The day's experience which I have detailed above, taken
with facts that had previously come to my knowledge, quite
convinced me of the communicability of the disease; but
as this is a most important and crucial point, both from
the theoretical and practical points of view, I subsequently
Communicability of Kála-ázar.
153
tramped over 150 miles from village to village along roads and
across country, chiefly in the Mangaldai district (as, owing to
the comparatively slow spread of the disease there, it offered
the most favourable field for my inquiries), in order to collect
convincing evidence on this point. The results confirmed and
extended those previously obtained, and left no possibility of
doubt in mind that the popular, and nearly universally-held,
view of the communicability of the disease was based on
absolutely uncontrovertible facts. A few of the more typical
and practically important instances only need be given here,
taken from notes made in the villages in course of this part of
my inquiries.
The following history of a basti (collection of houses) in
Mangaldai town is of great interest from several points of
view. The first case was that of a boy who was brought by
his mother when suffering from the disease to stay with a
relative in this village. They brought him in the hope that
he might get rid of his fever here. He only stayed two weeks
in the village, and then was taken back to Gauhati, from
which place he had come, and he died there. At about the
same time, another woman brought her son, aged 17, who also
had kála-ázar, and they stayed one month, when they also
returned to Gauhati. These events occurred in the cold
weather, and up to this time none of the permanent inhabitants
of the village had suffered from the disease. A month or
two after these two boys had left, two men of the village were
attacked by kála-ázar. One of these lived in the house in
which the first boy had resided, while he was in the village,
and a year later his brother also died of the disease. The
other man lived in the house in which the young man from
Gauhati with kála-ázar had resided, but his wife, who was
the only person who lived with him, escaped. These two early
cases occurred at the beginning of the rainy season, and
during the rains it spread to others in the village, and
eventually two-thirds of the people died. A year ago, that
is at the beginning of 1896, they decided to move the site of X
154
Report on Kála-ázar.
their village, as the disease was still very fatal among them.
They moved to a different piece of land, which is between one
and two hundred yards from the old site. The deserted
site still remains unoccupied, for when it was proposed to
build police lines on it, all the men of the force so strongly
objected on the ground of the fear of infection, that the
proposal was abandoned. It took these people, who had been
reduced from about 600 to only 200, one month to effect the
move. They had at the time of my visit been a year in the
new place. During the year before they moved, they had 20
deaths from kála-ázar, and at the time of their moving, they
had two cases, which they took with them. One of these died
soon after, but the other recovered. Two new cases only
appeared in the last year, one of whom was noticed to have
fever very soon after they had moved, the other began early
in the rains. Of these last two, the former recovered and the
latter died. The two cases who recovered, or were at least
alive and much better in January 1897, are shown on the
right of the photograph cases at the Mangaldai dispensary,
which was taken in August 1896, opposite page 33. I have
met with other instances in which whole villages have been
moved to new sites during the cold weather, purely in order to
get rid of the disease, and it was very commonly done by the
Garos years ago for the same reason.
No more conclusive evidence of the communicability of the
disease could be wished for than that furnished by this instance;
but what is of the greatest interest is the proof which it
furnishes of the infection being of an indirect nature in some
instances, for the two sufferers from kála-ázar, who undoubted
-ly infected this village, had both left it a month or two before
the persons who resided in the very two houses in which they
bad lived, began to get fever. It is of course possible that
the disease may have a long incubation period, but this is very
unlikely, for the fact that I have met with an instance in which
a man got the fever within three days of arriving in Gauhati,
although he only stayed there one week, and then returned to
Communicability of kála-ázar.
155
his own village, which previously had not had a case, he died
of the disease and infected the place, which shows that the
incubation period may be very short, and other instances
point in the same way. The houses must in this case have
been infected during the residence of these cases, and
when the rains came on, the infection became active, which
is in accordance with the much greater prevalence of the
disease during this season of the year. The good effect of
moving the site of the village during the cold weather, as
is shown by their much greater freedom from the disease
in the ensuing rainy season, is of the utmost importance and
will be referred to again.
The peculiar distribution of the affected villages was well
seen around Mangaldai. Thus, although many of the villages
had been affected from four to six years, yet others, a few miles
off, or even in the middle of those affected, had so far entirely
escaped. Thus, in walking 11 miles due north from Man
- g a l d a i t o w n , a l o n g a m a i n r o a d , n e a r l y a l l t h e v i l l a g e s m e t w i t h
in the first 4 miles had suffered very badly from the
epidemic for several years past; in the next 3 miles, some
of them only had suffered, and these less severely, while in
the last 4 miles I could not find a single case. The
middle zone was the most interesting and instructive, as the
following case will show:—A village, 4 miles from Mangaldai,
had been attacked six years ago, and had lost 100 out of 600
inhabitants. Three miles further north was a village which
had only had one case, in the person of a girl, who had
married a man in the village nine months before having come
from a village, 4 miles further south, which had suffered
very severely from the disease. It was found, very soon after
her arrival, that she had had fever in her own village, and a
few months later she became very bad with it, so the people
of the village turned her out, as they said she had kála-ázar.
She went back to her old village, but here they also would
not admit her. She then went to her father, who lived in a
village just across the road from that in which her husband
X 2
156
Report on Kála-ázar.
lived; but as this village was also free from the disease, the
people objected to having her, but her father built a tempo-
rary hut for her outside the village, in the middle of the rice
fields, which were now dried up. I saw all the people in con-
nection with this case, and also the patient herself, who was
in a terribly wasted condition, and had a very large spleen and
liver, and dropsy of the feet, and I tried to get her sent to the
hospital, but this the father said would be against his religion
as long as he was able to support her. I mention this case
to show the terror the people have of the disease, and the
extremes they will go to in order to prevent it being introduced
into their villages, because, I am convinced that in the Mangal-
dai district, the spread of the epidemic has been partially
checked by means of this kind of action on the part of the
people. A similar condition of things was found along
another road which runs parallel to the one that I have just
described, but separated from it by a river and about three
miles of country. This is the main road north from the
Rangamati-ghát, and about 11 miles up it there is a village
two parts of which have had the disease for four or five years,
while the third part, which is separated from the rest by about
two hundred yards of rice-land, has entirely escaped. On
inquiry here the headman told me that ever since the disease
had been prevalent in this part of the district, he would not let
any one from his part of the village hold any communication
with the infected villages, and he carried this to such a degree
that when any of his people had relatives ill with the fever, he
would not allow them to be visited, even if they lived in the
other parts of their own village and if they died, their funeral
was not attended. This is of course against all their customs
and religion, and it must have required a very strong belief
in the communicability of the disease for such a thing to be
possible. The good effect was, however, undoubted, as every
other village but this one in the immediate vicinity had suffered
severely from the epidemics, This man had an idea that if
any one bought any article of value which had belonged to a