NationalLibraryOfScotland/medical-history-of-british-india huggingface dataset:
( 12 )
appears from the first, and nearly all of the other symp-
toms 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, though deficient in blood, is nearly always of
a dirty yellow tint, often accompanied by distinct icterus.
The absolute dead white, rather blueish than yellow, coloration,
met with in the larger proportion of kála-azár cases is never
met with in uncomplicated malaria. There is something
peculiarly pathognomonic about this appearance of the con-
junctivæ which, once thoroughly appreciated, is not easily
forgotten.
At this time, however, I had no idea as to what might
be the cause of the symptoms observed, and, while await-
ing an opportunity of making a post-mortem examination,
proceeded to make a series of cultivation experiments by
inoculating a considerable series of tubes of nutrient jelly
with blood from several patients. With the exception of a
few tubes, which developed accidental colonies of well-known
mildews, &c., such as will occur in any such series of
observations, these experiments gave entirely negative results.
These observations, and the fact that none of the cases
showed the least sign of paralysis, or disturbance of sensory
power, clearly showed that, whatever it might be, kala-azar
had no connection with the endemic palsy described by
Pekelharing under the name of beri-beri. I may here
mention that neither in kala-azar nor in the beri-beri of
coolies have I met with any truly paralytic symptoms
or any trace whatever of nerve lesions. Hebetude and an
excessive weakness which may simulate paralysis, are of
course the common characteristic of the last stages of these
maladies, as they are in other similar states of low vitality, but
it would be as erroneous to speak of this state as paralytic
as to so characterize the weakness of a man tired out by
severe exertion, for it depends, not upon any lesions of the
nervous system, whether central or peripheric, but upon
want of nourishment for brain and muscle.
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
state of chronic dysentery from which she had suffered during
the whole of the time she had been under observation. The
other changes were oedema and ascites, excessive anæmia of
( 13 )
all 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 pri-
mary 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 estimation 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 a million.
Other post-mortem examinations followed, and proved
incontestibly that, whatever kála-azár might be elsewhere, the
disease so called in Gauháti was undoubtedly anchylosto-
miasis. Such being the case, my next step was to gain
some preliminaiy familiarity with the appearances of the free
embryonic forms of the parasite, and, while still observing
such cases as presented themselves at the dispensary,
sufficient sets of preliminary cultivations were instituted to
ensure the ready recognition of the embryoes wherever they
might then be encountered. It may be well here to anticipate
an objection which might well be raised, namely, that embryonic
nematodes of different species resemble each other so closely
that one might readily confound rhabditic anchylostomes
with anguillulce and other nematodes found commonly enough
in the soil. The characters, however, of the bursa of the male
rhabdites are quite sufficient to distinguish our species from
any other nematodes likely to be met with in such situations.
Having made these preparations, I went into camp, proceeding-
first to the Chaygaon district, which had been pointed out as
the most favourable base of operations. I visited a large
number of kála-azár villages, but was much disappointed
in the opportunities they offered for clinical observation.
I saw, of course, crowds of cases, but the people could not be
persuaded to come to the dispensary for either treatment or
observation. There is a branch dispensary at Ghaygaon, and
there must be hundreds of cases of kála-azár within a radius
of a couple of miles of the building ; but, in spite of this, only
three or four cases attend daily, and the number of new cases
was quite insignificant ; and even if one carried a supply
of medicine with one, it was difficult to induce the sick to take
it. They have such a firm belief in the incurability of the
malady, that they are free to confess that even charms and
sacrifices to the gods are quite unavailing.
( 14 )
The remark recorded by Dr. Dobson of one of his patients
well illustrates the position they take up on this point.
He was trying to persuade an old woman to submit to
treatment by impressing upon her that kála-azár was but neg-
lected fever, the view of the malady which has hitherto been
universal with the profession. Replied she—" If I have got
fever I shall get well sooner or later anyhow, but if I have
kála-azár nothing can cure me, so what is the good of bother-
ing me with medicine ? " From the point of view I take of the
disease, there was a great deal of justice in the old lady's
remarks. Nothing that has been hitherto tried has had any
effect on kála-azár, 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 upon the system.
It is little use stopping the drain of blood from the
patient's veins, when his digestive powers have become so
utterly wrecked as to be quite unable to assimilate food to
replace the loss. The inefficiency in advanced cases of mea-
sures merely directed to expel the parasites is only too well
known to all tea-garden medical officers, who have much
experience in the treatment of anchylostomiasis. Even in
early cases, they are, I find, agreed that the expulsion of the
parasites is but the first step of the treatment, and is effica-
cious only as a preparatory measure to careful feeding up
on the " hotel system." An advanced case rarely recovers,
whatever one may do. It is just possible that such cases
might be conducted to recovery, could one place them in
the wards of a London hospital and feed them hourly with
peptonized liquid nourishment, but such measures are quite
impracticable amongst Indians, whose caste prejudices forbid
their touching any food save such as has been prepared by a
caste-fellow, even if one had the appliances for providing any-
thing more suitable. Even, in our dispensaries, the cooking is
of the rudest, and, amongst themselves, no native has the faintest
notion of sick-room cooking. What is food for the healthy
must serve for the sick also, and he who cannot digest half-
cooked dal and ill cleaned, sodden rice must necessarily die.
In the course of this investigation I must have micro-
scopically examined the dejecta of many hundreds of subjects,
sick and healthy, and nothing impressed me so much as the
inadequacy of native methods of cookery which it brought to
light. The rice is commonly so badly cleaned that one finds,
( 15 )
on washing away the finer particles, an enormous quantity
of whole rice-husks. Now this is a very different matter
from the comparatively finely-ground particles of husk to
to be found in our own brown bread, yet even this is so
irritating that the article has a well-known purgative action.
How much more irritating then must be the unbroken husk
of rice, which is more siliceous than that of any other grain,
and has extremely sharp points. In the case of dal it is
common to find it passed quite undigested, the cooking having
quite failed to soften the grain, which, if thoroughly cooked,
is one of the most digestible of foods. In jails, where we put
into practice on a large scale these imperfect native plans of
cookery, which at the best are only fitted to deal with small
quantities, this is even more marked than among the free
population, and is, I strongly suspect, one of the most import-
ant factors in causing the disproportionate amount of bowel-
complaints found in such establishments.
However, although it was quite impossible to make a
very minute clinical study of the disease, there was 110 diffi-
culty whatever of satisfying oneself of its enormous preva-
lence, for the people were ready enough to bring out their
sick and to converse about the disease, when one visited them
in their villages, however unwilling they might be to adopt
our methods of cure.
By making daily excursions from Chaygaon, a large number
of villages were visited, in some instances half depopulated,
in others with only a few cases, and while, as will be more
fully pointed out further on, cases of sickness of all sorts
were confounded with the epidemic cause of additional
mortality, by the panic-stricken villagers, it soon became
evident that by far the greater proportion were cases of
anchylostomiasis, and that it was this alone that was respon-
sible for the enhanced mortality.
One strongly confirmatory fact was that large numbers
of the villagers who did not as yet consider themselves as
absolutely ill, showed unmistakable symptoms of the disease,
and, after a little practice, it became easy to pick out from the
group around one, a number of such cases at a glance.
The diagnosis of the disease can only be made a matter of
certainty by the discovery of the ova of the parasite in the
dejecta, and even this test cannot be considered final until after
careful and repeated examinations.
( 16 )
It was, of course, impossible to induce the people to bring
specimens of their dejecta except in the very small number of
cases one met with in hospital. Owing to this, it was found
necessary to test the question of the prevalence of the disease
by collecting specimens of the dejecta of the inhabitants at
random ; but as they never go more than a few yards from their
own doors to perform the offices of nature, there is no diffi-
culty whatever in finding specimens, for, filthy as are Indian
villages in general, I never elsewhere have found the people
so thoroughly careless in this respect as in Assam.
Close by the houses are always to be found a number of
small, shallow pits, from which mud has been taken for
plastering the walls. As the Assamese has a constitutional objec-
tion to unnecessary exertion, these excavations are never more
than 10 or 20 yards from the house, and they are fond of utilizing
them as latrines, forming miniature, but horribly offensive,
open cesspits close to the dwellings. Of course, there is much
fouling of the general surface, as they will often defile the
ground absolutely beneath the eaves of their huts, to save
themselves going out in the rain, and are too utterly careless
about the matter to use any one place systematically, but
these pits are certainly their favourite place for the purpose.
By examining thus specimens taken at haphazard, it was often
found that, in badly-stricken villages, three specimens out of
every four would contain the ova of the parasite. Further, it
was found that the severity of the outbreak and the proportion
of specimens showing ova was generally proportionate. In
these pits, in the soil about the houses (though often show-
ing no signs of recent defilement) in the puddles in the streets,
and in the filthy shallow bhils, I repeatedly discovered the
free or rhabditis phase of the parasite, in all stages of growth.
Strange to say, however, in only one instance has a trace
of it been discovered in any specimen of ostensible drinking
water, and even this instance was a doubtful one. The worse
a village is affected with kála-azár the more easy is it to
discover evidences of the prevalence of the parasite.
After some stay in the kala-azar districts, I proceeded to
Upper Assam, and visited the tea-growing districts, where
anchylostomiasis has recently 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 anchylostomiasis with those I had just been
( 17 )
seeing so much of, under the name of kala-azar. Probably, one
of the reasons that has prevented the earlier recognition of
their identity is owing to the fact that no one medical officer
has had any very extensive opportunities of observing both
diseases. Goálpára, e.g., has been continuously under the charge
of Dr. Dobson, but that officer has never served in the tea
districts, while the tea cultivation about Gauhàti is too limited
to afford much opportunity of studying the diseases of coolies
to the Civil Surgeon there. Surgeon-Major Borah, on the other
hand, has had comparatively little opportunity of observing
kala-azar.
Owing to the very extensive drainage operations that
have been carried out on the level tea lands in the Lakhimpur
district, the malariousness of the localities inhabited by the
garden coolies must necessarily have been much diminished,
and they are much less obnoxious, in this respect, than any part
of either Kàmrup or Goálpára ; and for this reason, alike among
the victims of anchylostomiasis, and among the apparently
healthy, enlargement of the spleen is much less commonly met
with. Nevertheless, it is easy to find numbers of cases, which
exhibit as large spleens combined with anchylostomiasis, as
in the worst cases of kála-azár, and no one, in these cases,
appeared to consider the malarial complication as of other
than secondary importance.
Probably, we shall never hear of kála-azár in the tea
districts about Lakhimpur, because the cases will be at once
identified, and it will be said that beri-beri has spread to
the indigenous population, as, indeed, it already has, in the
instance of some villages near Dibrugarh. For the same reason,
when anchylostomiasis appears in the tea-gardens of the
Kàmrup district, it will be called, not beri-beri but kála-azár,*
and, as in that district, the deep drainage cuttings found in
the tea-gardens about Dibrugarh are not required, these will
no doubt be found to possess as large a proportion of enlarged
spleens as is found among the ordinary population.
What I found most noticeable in my tour in the tea dis-
tricts was that, while a great deal of money had been spent
upon improving water-supply, the provision of suitable lines,
and other sanitary projects, the matter of conservancy was
* It is a curious circumstance that, since the above lines were written,
the forecast therein made has proved to be a true one in the instance of the
Chunsali tea-garden near Gauhàti, where, though the management re-
turned the mortality as due to " anæmia ;" the Civil Surgeon describes the
outbreak as "kála-azár," exactly like that met with in the district, vide
Section XI.
C
( 18 )
everywhere entirely neglected. It further appeared that,
while these improvements have undoubtedly resulted in a con-
siderable improvement in general health, as far as anchylosto-
miasis is concerned, they seem to have been generally ineffec-
tual. These tours, including a week's visit to the immigra-
tion depots at Dhubri, which resulted in the discovery that the
disease is already present in 2½ per cent, of the newly-arrived
immigrants, occupied my time fully until the end of March.
Having thus satisfied myself that, in both diseases, the
mortality was alike due to anchylostomiasis, my duty clearly
resolved itself into making a careful investigation of the
life-history and method of infection of the parasite. A great
deal was already known, but many points were still doubtful,
more especially it was important to ascertain the best way
of destroying the infective embryos.
This task has occupied the greater part of my time
during the remainder of the period, but another, and very
tedious, business was the systematic examination of the
pathological material that had been collected. With the view
of supplementing the cultivation experiments made with the
blood of kála-azár patients, and which gave purely negative
results, I made and examined, under a high power, immersion
objective, many hundreds of sections of the organs of the
subjects of post-mortem examination. These sections were
stained in every possible way likely to reveal the presence of
bacteria, but without bringing to light anything specific, though,
in cases that had died of lung complications, I found the now
often described cocci, and made some other observations of a
similar character. Had any specific bacterium been present, it
could scarcely have escaped notice. The greater part of each
day, for over two months, was occupied in this work, so that
the examination was in no sense perfunctory.
This result forms a strong piece of negative evidence in
favour of the view that anchylostomiasis is the one and only
cause of the enhanced mortality, for nearly all epidemic
diseases have one by one been shown to be due to the action
of parasitic organisms, vegetable and animal, and, where the
cause cannot be shown to be due to the action of vegetable
parasites (bacteria), the probability must be in the direction of
an animal parasite, so that, wherever we meet with an epide-
mic of hitherto unknown character, we may fairly expect to
be able to refer it to one or the other category.
The examination of old records, and the preparation of
this report have also necessarily occupied a considerable time.
( 19 )
III.—THE PKEVALENCE OF Kala-azar AS JUDGED BY
AVAILABLE STATISTICS.
That the mortality from Jcald-azdr has been very serious,
is a matter about which there can be no doubt, but unfortu-
nately it is quite impossible to gain any exact idea of the
absolute number of deaths it has caused. It is certain that it
has, in many cases, nearly depopulated whole villages, and
caused such panic among the survivors that they have fled and
left the place entirely abandoned. Several places were pointed
out to me during my tour in the Chhaygaon district, where,
in some instances, the ruined habitations of families, which
had been practically exterminated by it, exceeded the number
still inhabited. In such instances, enquiries among the sur-
viving inhabitants would generally elicit the tale that most of
the inhabitants of these ruined houses had died, and that the
one or two survivors had taken to flight. It would not be
difficult to collect from the reports of district officials a
number of such instances, but their collection could serve no
useful purpose, as we should be still as much as ever in the
dark as to the extent of the prevalence of the disease.
The provincial vital statistics throw no light on the
subject. Taking the Kàmrup district as the best for our
purpose, because kala-azdr has only appeared within its limits
during the last few years, one would expect to find the annual
mortality for these years markedly increased ; but, whatever
be the extent of the fatality, it does not show itself in the
returns. During 1889, the total mortality of the Kamrup district
per mille was 27'20, which is only 0'29 per mille in excess
of the average death-rate of the preceding five years, an
amount well within the ordinary limits of annual varia-
tion, as may be seen by an inspection of the annexed
table, which gives the death-rate for each year from 1882
inclusive,· during which period the conditions and efficiency
of registration has been fairly uniform. The birth-rates are
also given, as the proportion they bear to the death-rates
gives one a rough test of the comparative efficiency of
registration during the years in question :—
c2
( 20 )
Mortality of the Kámrúp district from 1882—89.
Year.
1889
1888
1887
1886
1885
1884
1883
1882
Total death-
rate
per
mille.
27.20
27.64
22.83
29.18
27.59
27.39
25.60
82.88
Total birth-
rate
per
mille.
21.63
23.18
24.27
25.02
26.00
24.95
22.66
27.65
The great annual fluctuations, and their capricious rela-
tionship to the birth-rate indicate of course that registration
is as yet in its infancy in Assam, a fact which indeed is ad-
mitted, and adverted to, in each successive annual report. Still,
however defective registration may be, and however mislead-
ing as a measure of absolute mortality, the figures must have
some comparative value, and strongly suggest the conclusion
that the mortality from kála-azár has been somewhat exagge-
rated.
We hear nothing of kála-azár in the Kámrúp district up to
the year 1884. Then, creeping gradually up through the Goal-
para district, kála-azár first appeared in Kámrúp in 1885, and,
since then, has spread through the whole district, and is now
commencing to attack that of Nowgong. In spite of this, there is
no marked increase in the registered mortality. The year 1886
has, it is true, a mortality considerably higher than 1885, but
this is followed by a year of abnormally low mortality, in spite
of the fact that reports show that kála-azár was steadily on the
increase. The years 1888 and 1889 again return closely to
the average of preceding years.
In the Goálpára district, the death-rate has always been
higher than in Kámrúp, a fact accounted for, in successive
annual reports, as due to more efficient registration, but the
appearance of kála-azár is so nearly coincident with the in-
troduction of an improved System of registration that the
figures are valueless for our purpose.
( 21 )
The fact appears to be that kála-azár enhances the
sick rate more than of mortality. As to the number of sick, we
have no direct means of judging, but it must be very large, as is
shown by the serious decrease in the revenue of the affected
districts, owing to a considerable area having fallen out of
cultivation from want of hands to till it.
A man, so ill as to be unfit to work, is just as unable to
cultivate the land as a dead man, so that no doubt incapacity
as well as death accounts for a share of this abandonment
of cultivation, and may explain why it is that the revenue
returns are so much more affected than the vital statistics.
During the past year, in the district of Kámrúp alone,
the falling off in the revenue attributed to kála-azár, amounted
to Rs. 12,896, and as the separate holdings are as a rule very
small, few paying more than a few rupees per annum, this must
represent many hundreds of families either dispersed, or so
diminished by sickness and death as to be unable to cultivate
the land they had hitherto held. While, however, the in-
creased mortality has not been sufficient, at any rate in
Kámrúp, to make its mark in the very imperfect vital
statistics of the whole district, there can be no doubt that, in
individual villages the increase has been so enormous as
to attain a truly pestilential character. The fact is that
the distribution of the disease is extremely capricious, while the
individual outbreaks are sharply circumscribed ; one village
being decimated, while another, close by it, remains unaffected,
but, wherever the disease makes its appearance, in the course
of a few months, large numbers of people are attacked, and
the mortality of the place is enormously increased. This is
illustrated by a table, prepared in 1884, by the Civil Surgeon,
Dhubri, in which an approximation to the mortality from kála-
azár is obtained by tabulating the recorded mortality from
" fever " in the affected district. In the registers, all cases of
kála-azár are of course included under this term, and it is
well to remember that, in Indian vital statistics, the heading
really stands for nearly all diseases except bowel-complaints,
violent deaths, small-pox, and the small percentage of cases
seen by medical officers. When tested by actual medical
investigation, as I have seen done in the Central Provinces, the
number actually due to malarial fever is found to form a
comparatively insignificant percentage of the whole, but, as
a general rule, in all parts of India, somewhat the larger half
of all deaths recorded will be found to be included under this