NationalLibraryOfScotland/medical-history-of-british-india huggingface dataset:
Plan of work.
lostoma and the number found in each case, for in view of Dr.
Dobson's work (Section I), it is obvious that these worms
must be present in the great majority of kála-ázar cases in
considerably larger numbers than they are to be found in
the ordinary healthy people of Assam, if they are to be
considered an important factor in the causation of the disease.
(2) An examination of a number of healthy Assamese for
anchylostoma by the thymol method, controlled by a quantita-
tive examination of the blood, by which means the effect of such
numbers as might be found on the composition of the blood
of apparently healthy people, could be ascertained. These
observations were carried out in precisely the same way as
those of Dr. Dobson, in order that they might be strictly
comparable with his. The amount of fever from which
each man had suffered within the last two years, was also
noted to see what influence this had on the production
of anæmia. It was also expected that an indication might be
obtained as to whether the inhabitants of Assam had larger
or smaller numbers of anchylostoma than the imported coolies
had been shown to have by Dr. Dobson.
(3) An examination of the blood in both kála-ázar and
anchylostomiasis cases, in order to find out if the anæmia,
which is such a marked feature of each disease, is of the same
nature or not ; for it appeared to to be very probable that
the changes brought about by the action of the anchylostoma,
would differ materially from those produced by a persistent
and relapsing form of fever, such as kála-ázar has always been
described as being by all observers, with the solitary exception
of Dr. Giles.
(4) These observations to be controlled by a similar ex-
amination of the blood in cases of both anchylostomiasis and
chronic malaria as met with in districts where kála-ázar was
not present ; and it may be said here that this was always
looked on as the most hopeful method of solving the com-
plicated problem before me.
23
Report on Kála-ázar.
(5)Through the kindness of Dr. Waddell, Chemical Ex-
aminer, Medical College, Calcutta, arrangements were made
for an analysis of the amount of iron in the liver after death
in some cases of ká/a-ázar, as it has been recently shown
that this is much reduced in cases of anchylostomiasis, while
it is increased in chronic malaria.
(1) A bacteriological examination of the blood was also
necessary, and Professor D. D. Cunningham very kindly
promised to supply me with culture tubes, and to examine
any organisms which might be obtained, as for this purpose
a fully equipped laboratory is required. A search for the
plasmodium malariæ, and, if found, a study of its forms in
order to determine, if it differed from that met with in ordinary
malarial fevers, in some. such way, for instance, as the form
met with in the summer-autumn fevers of Italian authors
does, constituted a very important and hopeful part of this
section of the investigation.
(2) The performance of as many post-mortems as possible
on both kála-ázar and anchylostomiasis cases, with control
observations on medico-legal ones, and with the compliment-
ary microscopical examination of sections of the various
organs ; for, although Dr. Giles tells us in his report that he
spent over two months on this part of the work, he unfor-
tunately appears to have only examined his sections for bacte-
ria, and makes no mention of any pathological changes being
found, except in the intestines.
In this part of the work especial attention to be paid to
the presence of pigmentation of the organs, as this has been
shown by two French observers to be constantly met with
in chronic malaria, and is indeed a much more easily demon-
strated and universally accepted sign of the presence of
malaria in chronic fever cases than the presence of the plasmo-
dium malaria itself, owing to the great changes in the blood
rendering it unusually difficult to demonstrate the presence of
the organism in such cases.
24
General course of the investigation.
In these various ways it was expected that it might be
determined if the disease was either anchylostomiasis or mala-
ria, or a combination of the two ; and in the event of neither of
these alternatives proving to be in accordance with the facts
met with, the ground would be cleared for striking out on a
new line of work. If, on the other hand, any of these explana-
tions sufficed, then it would only be necessary to study the
exact present limitations and manner of spread of the disease,
in order to see if anything could be done to check it, and the
origin of the epidemic would also have to be investigated in
the light of any new facts that might be brought to light.
Arrangements were also made for observations of the
variations in the distance of the water from the surface of
the ground to be recorded in the wells of the jails of the
different districts, and similar observations were made in such
other places as were visited from time to time, in order to
determine if the distribution of the disease had any relation-
ship to the depth and variations of the ground water-level,
and if the places that suffered most severely were water-logged.
The results obtained will be found in Section VI.
THE GENERAL COURSE OF THE INVESTIGATION.
The progress of the investigation will very briefly be
described here, so that the way in which the facts on which the
following description of the disease is based, have been
accumulated, and the gradual steps by which I have been led
to my final conclusions as to its nature, may be apparent.
Active work was commenced at the beginning of May 1896
by an examination of all the cases in the Nowgong dispensary
and jail, minute notes in shorthand, and a full examination of
the blood being made in each case. A month was spent in
this way, including a good many post-mortems, in which re-
spect I was particularly fortunate. As many as possible of
these cases were kept under observation, and followed up in
the intervals of my tours when I returned to Nowgong, for
Report on Kála-ázar.
many months, a matter of great importance, and one, the neg-
lect of which was responsible for much of Dr. Giles' mis-
fortune. The main impressions I derived from this first
month's work, were the constancy of marked fever and signs
of chronic malaria, and the difficulty of finding anything like
a typical case of anchylostomiasis in other than ex-tea garden
coolies. These cases were nearly all in an advanced stage of
the disease, only such being usually seen in a civil hospital, so
I determined to visit some of the affected tea gardens, where
I hoped to be able to find early cases, and to follow them up
by returning to visit them at intervals. I received most ready
assistance from Drs. Price and Lavertine, who hold medical
charge of the tea gardens of this district, the former in parti-
cular having had a very large experience of the disease, which
he freely gave me the benefit of. A great difficulty, however,
arose, for, although all were agreed that kála-ázar began
with fever, which continued on and off until the spleen and
liver became enlarged, yet no one even pretended to be able
to diagnose the fever of kála-ázar from that due to simple
malaria in the early stages, and only designated cases as kála--
ázar when fever had persisted for a long time, and symptoms
of chronic malaria had become developed.
I therefore decided to examine a series of cases of early
fever, of such a nature that the patients could not be said to be
suffering from kála-ázar, but some of whom had lost relatives
of the disease, and were therefore likely to be early cases of
it. Notes and blood examinations were made as before, and
temperatures taken four times a day. About a month
or six weeks later, I went around again and re-examined all
the cases. Some of them had recovered, and had apparently
only suffered from ordinary malarial fever, while others had
continued to be affected by it, and now presented the typical
appearance of kála-ázar. On comparing the notes and the
blood examinations, including the search for the plasmodium
malaria, no difference could be found in the early stage
26
General course of the investigation.
between those who had become kála-ázar cases and those
who had ordinary malarial fever, nor could any difference be
found in the sketches of the plasmodia, which had been
found alike in both classes of cases, nor did these differ in
any way from those which I had found as a result of six
months' continuous work at Doranda in Chota Nagpur in one
hundred cases of quotidian and tertian ague. This was very
disappointing, as I had hoped by these means to be able to
differentiate the early stages of kála-ázar from simple mala-
ria, a point of the first importance in view of the general opi-
nion, that the former disease is in some way or other infectious,
for if they could be isolated in the early stage, the disease might
be prevented from spreading on a tea garden or elsewhere.
On the other hand, I recognised that my failure in this respect
was in accordance with the experience of everyone else who
had studied the disease, with the exception once more of
Dr. Giles, who unfortunately began work at the end of Nov-
ember, at which time of the year chronic cases of kála-ázar,
such as he must have met with in the Gauhati dispensary,
often lose their fever for even months at a time ; and as he
admits that the longest time he had any one case under ob-
servation, was one month, while the great majority of his cases
he probably only saw once, it is not surprising that he denied
that fever is a marked symptom of the disease, especially as he
attributed any history of it which he acknowledges, he usually
obtained, to meaning simple, that the patient had been feeling
ill. It must then be admitted that the fever of kála-ázar is
in its earlier stages indistinguishable from ordinary malarial
fever.
At the same time, by means of re-examining the blood
of cases at intervals of from two to four weeks, I found that
the anaemia was in direct proportion to the amount, and more
especially to the height of the fever ; and that if fever was
absent for a few weeks, the blood immediately improved, only
to fall again if the fever returned. It was then evident that
27
E 2
Report on Kála-ázar.
the fever was the direct cause of the anæmia. Moreover,
when I visited the tea gardens in June, I was able to get
sufficient cases of pure anchylostomiasis to study the blood
changes, and to compare them-with those found in kála-ázar.
The result exceeded my most sanguine expectations, for it
became apparent that the anæmia of the two diseases was
absolutely distinct, so that given a drop of blood from a
typical case, I could, without fail, tell whether it was from a
case of kála-ázar or from one of anchylostomiasis, without
seeing the patient at all. Moreover, in the very small per-
centage of kála-ázar cases, which were complicated by an-
chylostomiasis (by which term I mean disease produced by
anchylostoma, and not merely the presence of the para-
sites in small numbers), the blood changes were intermediate
between those of the two primary conditions. I also found
that cases did occasionally occur in which the two diseases
so closely resembled each other, that they could not be dis-
tinguished clinically, but could be immediately diagnosed
correctly by the blood examination. Further, my experience
shows that anchylostoma are _not present in quite as large
numbers in cases of kála-ázar as they are in the healthy
people of this district, the small difference being doubtless
owing to some of the former having been given thymol. I
have also found that the numbers in which they are present in
kála-ázar, are too small to have any appreciable effect on
the blood, for in the healthy jail-people larger numbers were
present without the slightest alteration of the blood ; but
that those of the jail population who had had more than one
week's fever in the last two years, had distinctly poorer
blood than those who had had no fever in the same time.
It is evident then that kála-ázar is quite distinct from
anchylostomiasis, and that only in a very small proportion of
the cases is it complicated by the latter disease.
It now became necessary to take in hand the section-cut-
ting, and as ice could not be obtained in Nowgong, and it was
28
PLATE I.
Photo-etching. Survey of India. Offices, Calcutta, May 1897
GROUP OF ORDINARY CHRONIC MALARIA IN SYLHET.
General course of the investigation.
much too hot to freeze with an ether spray, an adjournment
was made to Shillong, where the greater part of October was
spent with this and other work, with the result of showing
that marked pigmentation of the liver, spleen, and kidneys, was
a constant pathological feature of the disease, and was
not found in cases of anchylostomiasis, or in persons who
had died of snake-bite or from accidents, provided no
malarial complications were present. These observations
then furnished absolute proof of the malarious nature of the
disease, and it now remained to be determined if the disease
could be differentiated from ordinary chronic malaria.
For this purpose it was necessary to examine cases of
chronic malaria in some place where there was no kála-ázar,
for they certainly cannot be clinically distinguished in such
a place as Nowgong at the present time. Sylhet, which had
never been affected by the epidemic, was therefore visited, and
some cases of advanced chronic malaria were kindly obtained
for me by Dr. Banerjee. As will be seen by comparing the
photograph opposite this page with those opposite pages 33
and 57, they were clinically the same as kála-ázar, and, in
a district affected by the latter disease, would inevitably be
returned as such. Nor did the blood changes show any
points by which they might be distinguished. The symptoms
were also identical, yet there was this very marked differ-
ence between the two classes of cases, for on enquiring into
the history of them, it was found that, roughly speaking, they
had suffered from fever on and off for about as many years
before they developed this extreme form of malarial cachexia,
as kála-ázar cases take months to reach the same stage,
and moreover they were widely scattered in their distribution,
it having taken two or three days to collect six cases, and no
two cases occurred in the same family ; while, on the other
hand, in the case of kála-ázar, the course of the disease is
very rapid, and the fever very intense, and it has a very great
tendency to run in families, and even to kill out whole
29
30
Report on Kála-ázar.
villages, so much so that I know of one educated native of
Nowgong, who has lost 39 relatives in six years, and has only
four near ones now living. In short, the Sylhet cases are
ordinary endemic cases of chronic malaria, such as are to be
met with in any highly malarious district, while kála-ázar is
equally malarial in its nature, but it is of a peculiarly intense
form, which has the power of spreading slowly through
districts, and killing off the majority of the inhabitants of
villages, and more especially of families, to such an extent that it
must be in some way communicable: in a word it is epidemic.
It now became necessary to study the origin, spread, and
present limitations of the disease. For this purpose the Garo
Hills were first visited, and an examination of the records, as
far back as 1870, yielded much interesting information as to
the exact time and places where the disease first appeared in
that district, and afforded a clue as to real origin of the disease,
which was subsequently successfully followed up. Tours in
the Nowgong, Mangaldai, Tezpur, and Golaghat divisions, were
then carried out, and evidence as to the mode of spread and
limits of the disease was obtained. These tours, together with
the writing of this report, occupied the whole of the cold-wea-
ther months. The results of this latter part of the work will
be found recorded in Sections VI—VIII.
(31)
SECTION III.
CLINICAL DESCRIPTION OF KÁLA-ÁZAR.
Although kála-ázar has been briefly described by many
writers, yet doubtless owing to the difficulty of following
up cases and the impossibility of diagnosing them from ordin
-ary malarial fever in their early stages, I have not been able
to find any complete clinical account of the disease, such
important points as the cardiac and retinal changes being
scarcely mentioned. The following attempt to supply this
deficiency is based on short-hand notes of nearly 100 cases,
a great many of which have been repeatedly examined and
followed up for months, and also on details of the exact admis
-sions and dates of the deaths or recoveries of 200 cases, which
occurred on a tea estate in the Nowgong district, which were
taken direct from the hospital books by the kind permission
of Dr. Dodds Price, who had seen all the cases during life, and
could, therefore, vouch for the substantial accuracy of the
diagnosis, and who has given me invaluable assistance in this
and other work on the gardens under his medical care. This
laborious part of the research has presented opportunities
as unique as they were invaluable in solving several of the
problems connected with the disease.
Kála-ázar may be defined as being a chronic and relaps
-ing form of fever of an intermittent or irregularly remittent
type, which is very resistent to treatment, and produces pro
-gressive anæmia, great wasting, and in many cases dropsy,
and terminates either in a final attack of fever or in asthenia,
often accompanied by diarrhœa or lung complications; it
attacks usually several members of a household, and spreads
slowly through districts in a wave of increased fever mortality,
and after about six years dies out again.
The diagnosis of the cases is obviously of the first import
-ance, as if it is incorrect, the results based on it will also be
wrong. Unfortunately, it is quite impossible to tell early cases
32
Report on Kála-ázar.
of kála-ázar from ordinary malarial fever, and I find that it
is not until fever has persisted steadily on and off for some
months, and signs of cachexia, such as anemia, enlarged
spleen and liver, etc., have supervened, that cases are called
kála-ázar. If, in addition, there is a history of other cases
in the family, or in the house in which the patient has lived,
then the diagnosis may be made with confidence. Doubtless,
cases of ordinary chronic malaria and of anchylostomiasis
and other forms of anæmia, which happen to be complicated
by enlarged spleen, are not unfrequently returned as káia
-ázar, and I have met with such cases which could not
be diagnosed correctly by ordinary clinical methods, even
after I had had considerable experience of the diseases.
Fortunately, a method has been found of differentiating
anchylostomiasis even when complicated by enlarged spleen
from kála-ázar, namely, by the blood changes, which will
be described in detail in the next section, and it will
suffice to say here that no doubtful case has been included
in the series on which the following clinical description
is based, that has not been submitted to this test, with the
exception of those on the tea garden, which have only been
used to get some idea of the duration and seasonal distri
-bution of the disease, and the number of which, all of whom
have been under the care of Dr. Price, is sufficient to do
away with all chance of appreciable error in the limited
deductions drawn from them.
The spread of the disease will be described in detail
as far as it can now be traced in Section
VI, and only the incidence in families will
here be dwelt upon. It has already been mentioned that the
disease has a marked tendency to affect several members of
the same family, and, as was pointed out by Dr. Giles, several
members of one household are often attacked before any
other family of the same village suffers, although they are all
living under the same meteorological and sanitary conditions.
The distribution of
the disease.
PLATE II.
Photo,etchtng.
Survey of India Offices. CalcuttaApril 1897.
GROUP OF CASES OF KALA AZAR AT MANGALDAI.
Clinical description of Kála-ázar.
33
The exact number of persons in each family of my cases was
noted, both as to how many had suffered from, or died of, kála-
á zar and how many had escaped the infection. Taking only
the Nowgong dispensary cases, the following very remarkable
figures were obtained. Among the relatives of 20 cases, 123
had suffered from kála-ázar, all but 2 dying of the disease, while
only 44 had escaped; or to put it in another way, no less than
four-fifths of the cases had lost half or more than half their rela-
tives from the disease in the course of from three to five years.
Cases, who had no relatives in Assam, as was the case with
some imported coolies, were omitted from this calculation.
This, taken with the facts to be mentioned in Section VII,
is sufficient to prove that the disease is capable of being
contracted in some way or other by living in a house in which
infected persons reside. This was also Dr. Giles' opinion,
although the explanation of the fact, I believe, to be very
different from that which he propounded. It should be men-
tioned that the dispensary cases show a stronger family history
than the general average, owing to the presence of some
children who had lost their parents and other relatives from
the disease.
The disease has been described in its general features so
often, that only a few words need be
written here on this part of the subject,
especially as it will be necessary to go into considerable
detail on those symptoms of the disease regarding which my
observations differ very widely from those of Dr. Giles. A
typical group of cases at the Mangaldai dispensary is shown
in the photograph opposite this page. The man on the left
had only suffered from fever for a short time, but it was
thought that he might be a very early case of kála-ázar.
However, he soon recovered, so probable had only ordinary
fever, but he serves as a good contrast to the other definite
cases of the disease. As already mentioned, the early stages
of the disease cannot be distinguished from ordinary malarial
fevers, while the latter stages resemble in every respect very
F
General clinical de-
scription of kála-ázar.