NationalLibraryOfScotland/medical-history-of-british-india huggingface dataset:
212
Report on Kála-ázar.
persons suffering from it coming to live in the town, usually
with relatives. This is quite impossible to put a stop to
under the present laws, but the question arises whether the
dangerous condition of affairs, both with regard to Tezpur
town, and also the threatened spread of the epidemic into Go-
laghat and the more easterly parts of the Assam Valley, is
not sufficiently grave to render it advisable to take advantage
of the provision of the Epidemic Diseases Act passed recently,
which reads
—
" In the event of India or any part thereof being at any time
visited by or threatened with an outbreak of any dangerous epide-
mic disease, the Governor General in Council, if he thinks that the
ordinary provisions of the law for the time being in force are in-
sufficient for the purpose, may take such measures, and by public
notice prescribe such temporary regulations to be observed by the
public, or by any person or class of persons, as he shall deem neces-
sary to prevent an outbreak of such disease, or the spread thereof."
Now there can be no question but that kalá-ázar is a
"dangerous epidemic disease" within the meaning of the Act,
while there is good reason to believe that in the course of its 20
years' uninterrupted spread through the province, it has caused
much greater suffering and loss of life than even plague itself
would be likely to do, supposing it to gain access to Assam;
for the latter, although very virulent while it lasts, seldom re-
mains in a place, especially comparatively small towns, for more
than a few months, while it does not cause the terrible dying-
by-inches of whole families that kála-ázar does. If then
powers were taken to send back to their own villages any cases
of kála-ázar which might be found in other unaffected or re-
cently infected districts or towns, which would also cover the
case of whole villages migrating to uninfected parts, as I know
to have occurred from Nowgong to both Golaghat and the
interior of the Tezpur district, then a very great step would
have been taken to prevent the infection of new places and
divisions; and the very fact of such powers being in existence,
would tend greatly to prevent occasions arising for their
exercise. Moreover, I have met with more than one instance
Recommendations. 213
in which the people were most anxious, for powers to expel
cases of kála-ázar from their village, so that such a measure
would be welcomed by them. I am strongly of the opinion
that the circumstances both warrant and necessitate the use
of this measure if the upper parts of the valley are to be saved
from the calamity which threatens them.
In addition to this the moving infected collections of
houses in the town of Tezpur, or other large places
which may become infected, should also be enforced, as I
have already , recommended in the case of the busti opposite
the club in Tezpur, the particulars of the infection of which
have been given in Section VII, page 160. It is a doubtful
question whether this can be done compulsorily under the
Municipal Act on the ground that it is a necessary sanitary
measure, if not powers of doing so should be prescribed
under the Epidemic Diseases Act for towns and any other
places where it might be thought to be desirable.
(3) Unaffected but threatened districts.— The most im-
portant of these is the Golaghat subdivision. For the more
easterly parts of the Sibsagar district and that of Dibrugarh,
are not likely to be affected except through Golaghat. If
then Golaghat can be saved, the whole of the upper end of the
valley on the south bank of the river will also be spared, while
North Lakhimpur will probably also escape, although this divi-
sion is too sparsely populated to be likely to suffer severely
from the epidemic. This is the most important, and also the
most hopeful part of the problem, for, as has already been said,
there is a better opportunity of stopping the easterly extension
of the disease at the present time than there has ever been
before, or is ever likely to occur again if it is neglected now,
while if nothing is done the epidemic seems certain to spread
to the end of the valley.
The principles on which successful action should be
based are still the same as in the previous instances, but re-
quire most thorough carrying out if they are to be efficient.
The principles are to prevent, as far as possible, the entry into
214 Report on Kála-ázar.
the district of any persons suffering from the disease by
continuing the watch, that has been kept on infected persons
travelling up along the grand trunk road from Nowgong into
Golaghat, sending back any that may be detected, which
appears to have been so far successful in keeping out the
disease, and extending it to the lines of communication from
infected districts by the river, for which purpose again a
special notification under the Epidemic Diseases Act may
be required; and secondly, finding out the first villages in
the district to become infected by the disease, warning all the
people around them against having any communication with
them, and in the cold-weather months making them move
from the infected site to a short distance where they will still
be under observation.
The most essential point then is to detect the very first
villages that get the disease, and these are nearly certain to
be either in the mauzas adjoining the Nowgong district, or
in those through which the traffic from the river passes, and
will very likely be first found in some of the larger places
which have most active communication with infected districts.
The earliest information can be obtained from the mauzadars
of these parts, while a careful watch should be kept for any
notable increase in the death-rate in each separate mauza,
especially during the rainy season.
My first proposal, namely, the distribution of a pamphlet,
pointing out the usual methods in which
infection of villages and families takes
place, should be carried out as soon as
possible, as the season when the spread of the disease is
most active, namely from April to October, has already
arrived.
The measure of moving the sites of villages that have
become infected can only be carried out in the cold weather,
so that there will be ample time for a full consideration as to
how and where it can best be carried out, and in the mean-
time it will be necessary to collect information as to the exact
The best ways of
carrying out the pro-
posed measures.
Recommendations.
2 1 5
distribution of the disease mauza by mauza, and village by
village, in order that when the short annual time for action
comes, a decision may already have been arrived at as to where
the measures shall be adopted, by which means no time may be
lost, especially with regard to the Golaghat division, where
most careful inquiries should be made during and towards the
end of the ensuing rainy season (1897), as to whether any
villages have already been attacked by the disease.
The advisability of taking advantage of the provision of the
Epidemic Diseases Act, as proposed, will also have to be care-
fully considered both with regard to towns and uninfected,
districts, more especially Golaghat.
The subject of the headings under which deaths from this
disease have been registered, and the cor-
rectness or otherwise of the classification,
must be briefly referred to. In this connection I would like
to point out that one of the main obstacles to the all-important
early recognition of the beginning of the epidemic in any
district or part of a district is largely due to the generally
acknowledged deficiencies of the present system of registration
of deaths by an unpaid agency in all the districts of the
Assam Valley, with the exception of Goalpara, which is
the only one in which anything approaching accurate figures
are obtained. The remedy for the defect is as well known as
the defect itself, and the difficulty in its adoption is a financial
one. I think, however, it is worthy of consideration whether
the present position of the Golaghat subdivision does not
warrant a system of paid chaukidars similar to that in force
in the Goalpara district, being introduced there for the
registration of deaths in order to ensure the earliest and most
correct possible information of an increased death-rate from
fever in any part of the division being obtained.
Since September 1891, deaths have been returned under the
heading anchylostomiasis, which is further subdivided into ( a )
anæmia or beri-beri of Ceylon, and ( b) kála-ázar. Nothing
could illustrate better the hopeless state of confusion which
Registration
of
deaths.
216 Report on Kála-ázar.
ensued on the publication of Dr. Giles' report than this extra-
ordinary nomenclature; for apart altogether from the absurdity
of expecting the ignorant village headmen who register the
deaths to differentiate between these diseases, which have
been such a source of controversy for so many years and the
subject of two special investigations, it will now be evident
from the facts recorded in this report that two or more totally
distinct diseases have been returned under one heading, while,
as Dr. Giles himself pointed out, true beri-beri does not occur
in Assam, although, unfortunately, he used the term on the
title page of his report.
It has been shown that before the adoption of these terms
cases of kála-ázar were correctly returned under the head
of fevers, while in the last few years in more especially the
Nowgong district, a large proportion of ordinary malarial fevers
have been returned under the head of kála-ázar. The fact
that kála-ázar is nothing but an intense form of malarial fever,
which is not always easily distinguishable from the ordinary
type, even by an experienced medical man, will be sufficient
reason for reverting to the previous arrangement whereby these
cases were returned under the head of "fevers." The deaths
from fevers (and also from kála-ázar if the term is retained),
in each mauza of the affected districts should be permanently
recorded in the office of the Sanitary Commissioner, in order
that the yearly progress of the epidemic may be easily and
accurately followed in the future.
With regard to the term anchylostomiasis the facts already
recorded, together with some further details which will be
found in an appendix to this report, prove that the particular
form of anæmia which is brought about by the anchylostomum
parasite, and is therefore rightly called by the above name, is
not distinguishable from anæmia due to the numerous other
causes which are in active work in the Assam Valley, except
by the use of the microscope or by giving thymol and counting
the worms that are passed, and even then it will in the
majority of the cases be only one factor in the production
Measures to be taken on affected lea gardens.
217
of the anæmia; so that, apart once more from the impossibility
of the diagnosis being made by the registering agents, the
condition of vital statistics of the province and our present
state of knowledge do not appear to be at present sufficiently
advanced to render the retention of this term advisable. If
a substitute be required, the simple term "anæmia" would be
the most suitable, but even this is open to the objection that
many cases of kála-ázar would be likely to be returned under
it, which is just what is most desirable to avoid, and moreover,
severe anæmia is not common among the indigenous
population of the province, apart from those who work on tea
gardens, except as a result of malarial fever.
The term "anæmia of coolies" should, however, be
retained in the returns from tea gardens, but I am doubtful if
the term anchylostomiasis is advisable here either, as there is
certainly a tendency to enter any case which has been given
thymol under this heading, which will include practically every
case of anæmia due to whatever cause, whether there were
any of the worms present or not, while I have shown in the
appendix that this disease is only one of the many causes
of anæmia on tea gardens, although it is undoubtedly a very
important one.
MEASURES TO BE TAKEN ON AFFECTED TEA GARDENS.
The first difficulty which is encountered with regard to
kála-ázar on tea gardens is the early
recognition of the disease, but it is hoped
that the illustrated clinical description of the disease, which
forms a large part of this report, together with the clearing
up of the confusion which has hitherto surrounded the
subject, may be of considerable help in this respect. On
the other hand, it must be remembered that the disease has
been mistaken for a general but unexplained unhealthiness
of an affected garden until it had gained a firm hold and
had considerably increased the death-rate, which is not
surprising, considering that it is but an intense form of malarial
2 F 2
The early recogni
-tion of the disease.
Measures to be taken on affected tea gardens.
219
on other gardens, and at a later date than is usual on the
suspected one, in the absence of unusually late rains or
other abnormal cause, then it will be pretty certain that the
epidemic has begun.
If the disease be recognised on the occurrence of the first
few cases, as should in future be the case,
then the measures to be taken will be simple,
and will be comprised in the following
suggestions. If the affected coolies be local labourers, their
services will be at once dispensed with, together with any
from their villages or other infected ones from which
labour may have been derived. In fact, any garden which
employs local labour or has infected villages near it, should
take care to keep itself informed of any neighbouring villages
which are suffering from this communicable type of fever, and
all their coolies should be warned against visiting them. If
the infected coolies be imported ones, they should at once be
sent into hospital, and, if possible, placed in a separate building
to other patients, and kept there until the case terminates in
death or complete recovery. The other inhabitants of the
house from which he comes should move into another one
by themselves, and carefully watched for fever, and the infect-
ed house destroyed and its site abandoned. It has been
proved by actual experience that it is of little or no use to
simply remove those who already present well marked signs of
the disease, for the houses in which they have lived are certain
to be infected before the first case which has occurred in it can
be diagnosed with certainty, and some of the other occupants
will develope the disease if they remain in them. The infect-
ed houses should therefore be burnt down, and not rebuilt.
The simple burning of the thatch roof within the mud walls
of the house and then re-roofing it, has been followed by
other cases occurring in the same house. If only a very few
cases have occurred, the above measures may be sufficient
to eradicate the disease, and the importance of its early
recognition and of prompt measures for getting rid of it cannot
Measures to be taken
if the disease is detect
-ed early.
Measures to be taken on affected tea gardens.
221
weather he moved his coolies into them, and burnt down
the old infected ones. From that date he scarcely had a
fresh case of the disease, and the epidemic died out. In this
case the disease had been present on the garden for some four
years, and it does not necessarily follow that quite as good a
result would have followed if the move had been made in an
earlier, and perhaps more acute stage of the outbreak,
unless the precautions to be immediately mentioned are adopted.
The same plan is now being tried in the case of a newly-infected
line on a garden in the north of the Mangaldai district, so that
by the end of the rains of 1897 more definite information as
to its utility in this stage will be available, while in the garden
of the Nowgong district, which has been already mentioned
as having suffered so severely from the epidemic malarial fever,
similar measures have been carried out in one of the lines.
The following measures are those which are to be recom
-mended in the case of coolie lines which have become infected
with the disease to a greater extent than that already
discussed, namely, when cases have occurred in many of the
houses of the lines
—
(1) All new coolies should be placed in new lines, and on
no account should they be put into the infected lines
for a single day. The importance of this is very great, and
when it is pointed out that for the cost of a single coolie
accommodation can be constructed for thirty or forty, the
economy of this measure will at once be evident, and it
will also be the first step towards giving up the infected lines
altogether. Convincing evidence of the efficiency of this mea
-sure and of the bad result of its partial neglect, will be
found in the example recorded on page 163.
(2) The infected lines should be evacuated during the
cold-weather months when the fever is at a minimum, the
best time being in the months of January and February, and
it should be completed before the first few inches of
rain falls, which usually occurs in Assam in March or April.
222
Report on Kalá-ázar.
Fortunately this is just the time when, if the pruning is well
in hand, labour can most easily be spared for the work of
building new lines. In carrying out this measure, the
following precautions will be advisable in order to prevent
the infection being carried into the new lines. All those
families who have had no cases of the disease among them,
should undoubtedly be moved into the new lines, and this
measure will be certain to result in many of them escaping
the disease who would otherwise have suffered from it during
the ensuing rainy season. The difficulty is to know what to
do with those families who have had cases of the disease
during the previous rains, but none of whom have any
fever at the time of the proposed move. If none of them
have been getting fever of a persistent nature during Novem
-ber and December, that is after the ordinary fever season is
over, they may be safely moved, but any families who have
definite cases of the disease among them, or who are con
-tinuing to get fever during the cold-weather months, should
not be moved into the new lines, but if they can be got out
of the infected ones and put in separate ones, it would be the
best thing for them. It would be advisable not to build very
elaborate houses in the new lines in case the disease should
break out in them and a second move be necessary, although
this is not at all likely to be the case, especially as any early
cases which might occur there would be detected and
dealt with as suggested in the recommendations to be taken
when the infection of a garden is found out early.
CONCLUSION.
I regret the great length of this report, but the confusion
in which I found the subject involved has necessitated a full
and systematic clinical and pathological description of the
disease, while it was also essential to record ample and
convincing evidence as to the communicability and
origin of the epidemic. The facts have, as far as possible,
Conclusion.
223
been left to speak for themselves, and discussion has been
reduced to a minimum. It is hoped that a sufficienlty
intelligible and comprehensive account of the epidemic has
been given to serve as a basis for ameliorative and prevent-
ative measures.
LEONARD ROGERS, M.B., B.S., London, F.R.C.S., Eng.,
Surgeon-Captain, I.M.S.
SHILLONG, 31 st March 1897.
Photo-etching.
Survey of India Offices, Calcutta, April 1897.
PLATE IV
GROUP OF CASES OF ANAEMIA OF COOLIES.
APPENDIX No. 1.
ON THE ANÆEMIA OF COOLIES.
In the course of my investigation into the origin and nature of
kála-ázar, much work has been done on the subject of anchylos
-tomiasis and other conditions in which anæmia is a marked feature,
in order to differentiate these from the former disease with which
they had been confused. In the course of this work, some results
have been arrived at, which do not enter into my general argument
on the subject of epidemic which has, for so many years, been
spreading up the Assam Valley, but which may be worthy of
record. It is therefore proposed to embody them in this appendix.
As, moreover, my work has necessitated visiting nearly every dis-
trict in the province of Assam, and has afforded me unique opportu
-nities of learning the views of those best qualified to form an opinion
on the difficult subject of the causes of the anæmia, which is still very
prevalent among tea garden coolies, the conclusions which I have
arrived at, after a perfectly unprejudiced examination of the question,
may be of some interest to other workers on the subject, even
though there is very little that is original in my observations.
The adoption of the heading of anæmia of coolies rather than the
term anchylostomiasis is due to my belief that the latter is only one
out of many causes of the disease, and it is largely with a view to
pointing out some other factors to which I think sufficient attention
is not paid that the following notes have been written:
The groups of cases of anæmia of coolies in the photograph opposite
this page illustrates very well the differences both in type and degree
of the class of cases which are grouped under this heading. The two
cases on the right represent moderately advanced cases of the drop
-sical type of anæmia, while the two on the left show advanced cases of
the same, the extreme left one being the worst that I have met with.
The central man's anæmia was due to chronic dysentery, and the
absence of dropsy in this case imparts to him a very different
appearance to the other cases. The type of his anaemia was also
different to that of the others, as his hæmoglobin was less reduced
relatively to the number of the red corpuscles. The whole group
presents a very different appearance to that of the kála-ázar cases
shown in the illustrations opposite pages 33 and 57.