NationalLibraryOfScotland/medical-history-of-british-india huggingface dataset:
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SECTION X.—PREVENTIVE AND REMEDIAL MEASURES, page 129; the
obvious necessity of measures of conservancy and the futility of other
sanitary measures in anchylostomiasis, ib.; trench latrines, page 130;
dry earth latrines, pages 131-133; the disinfection of infected sites,
pages 133-135; purification of drinking-water, pages 135-136; futility
of medicinal, remedial, measures, page 136; abstract of recommenda-
tions, pages 137-138.
SECTION XL—ANCHYLOSTOMIASIS IN TEA-GARDEES, page 139; in
gardens long on the black list, the cause is generally anchylostomiasis,
ib. ; absence of exact statistics as to the prevalence of the disease, page
139; total mortality of gardens, page 140; steady rise in number of
black-listed gardens, page 141; table illustrating this, page 142; wide
diffusion of the disease among garden hands still at work, page 143;
in stance of Chunsali tea-garden, pages 143-145; the general sanitary
condition of coolies on tea-gardens, (a) housing, pages 145-149, (δ)
clothing, page 149, (c) food, pages 149-152; " the hotel system,"page
150, (d) water-supply, page 152, (e] conservancy, pages 153-156.
REPORT ON KALA AZAR AND BERI-BERI.
I.—INTRODUCTORY EEMARKS.
FOR reasons that will appear in the sequel, it will be in
no way necessary to enter into any separate description of
the maladies indicated by the above popular terms, as the
main result of the investigation has been to establish their
identity.
It is unfortunate that the word "beri-beri" should have
acclimatized itself as firmly as it appears to have done
in Assam. I refer of course to its use among Europeans,
because the word is unknown to the other inhabitants of the
province, whether Assamese, or imported Indians. The
fact is that " beri-beri" the " JcaJcke " of Japan, " kalà-azàr" and
another word, equally evil-sounding to English ears, in
popular use in South America, but which I am unable at
present to recall, all may refer to the same disease ; while
each has the added disadvantage of being popularly applied
to any disease that may bear a rough resemblance to what-
ever malady may be the commonest cause of epidemic
mortality in the particular region affected.
The confusion has been greatly enhanced by the efforts
of scientific men, who were conversant with a disease in
some one country, to identify the malady they had themselves
observed with diseases of other countries, of which they
had no personal experience. The word " beri-beri" however,
seems to have the widest acceptance, at least among
Europeans, but it is a curious fact that it has not even the
defence of being in popular use in the vernacular of any part
of the world.
On this point Dr. John Grant Malcolmson,* who wrote
a prize essay on " beri-beri" as observed in Madras, more
than fifty years ago, remarks—
"As to the appellation " Beri-beri" it appears to me perfectly unac-
countable how it could ever have crept into such general use as it has, for
* A Practical Essay on the History and Treatment of " beri-beri," by
Assistant-Surgeon John Grant Malcolmson, Madras Medical Establish-
ment. Vepery Mission Press, Madras, 1835.
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it is perfectly unintelligible to the natives from whom it is said to have
originated. Though the word "B'hay-ree" does really mean a sheep
in the Hindustani dialect, and hy repeating it (making allowances for
the orthographical error in persons unacquainted with the language, and
consequently of the proper sound of the word), we may form such a name
as beri-beri; yet, after the most particular enquiries on the subject,
I find the natives are totally ignorant of any disease under that title."
A disease, endemic in Ceylon, of somewhat similar
character, came to be called by European medical men by
the same name, from the supposed identity of the two
maladies, though, it need hardly be remarked, the word
has no more vernacular signification in Cingalese than in any
other dialect. This endemic, we now know from Dr. Kynsey's
pamphlet,* is established without doubt to be anchylostomiasis,
though it is quite possible that cases belonging to another
category may be found in that island in addition. We hear
much too of the ravages of " beri-beri " in the Dutch Indies,
but perhaps here with more justice, if we confine the term
to the disease as originally described in Madras. It will
be desirable to refer more fully to this point further on, but
no one can, I think, compare the descriptions given by
Malcolmson† and Pekelharing,‡ without being convinced
that they are describing the same disease ; and that this
disease is not anchylostomiasis, but an entirely distinct malady.
At the same time I think it more than probable that in both
instances a certain percentage of cases of anchylostomiasis
are to be found.
I know, from personal observation on coolies freshly
imported thence, that anchylostomiasis does exist, at the
present day, in the northern part at least of the Madras
Presidency, and it is hardly likely that the disease is at all
a recent introduction. Indeed, some few of Malcolmson's
cases appear best referable to that cause. On the other hand,
Professor Pekelharing actually found anclrylostomes in a few
cases in Achin. In climates so" favourable to the development
of the parasite as those of the Madras Presidency and Achin,
the spread of the parasite will be merely a question of the habits
of the natives, and while I doubt if such habits could anywhere
* "Beporton Anemia, or Beri-beri of Ceylon," by W. B. Kynsey.
Government Press, Colombo, 1877.
† Op cit.
‡ " Kecherches sur la nature et la cause du beri-beri et sur les moyens
de le combattre," par L. A. Pekelharing et C. "Winkler, Utrecht, Kremuik
et fila, 1888.
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afford more favourable opportunities for its propagation than.
in Assam, we well know that the sanitation of semi-civilized
communities is everywhere so backward that, given the
presence of the parasite among such communities, it can
hardly fail to find a considerable number of hosts.
Again, it seems possible that at any rate some of the cases
included under the name of " kakke " in Japan may be exam-
ples of anchylostomiasis.
In "Virchow's Archiv.," Vol. XXL, page 290, for 1877,
Wernick wrote a paper on the Japanese variety of beri-beri,
which, as I gather from Pekelharing, was devoted to proving
beri-beri to be a pernicious ansemia. Pekelharing devotes
several pages to demolishing this view, pointing out that ane-
mia is by no means a necessary, or even common, symptom of
beri-beri (as he had seen it), never apparently suspecting that
he and Wernick may have been observing two entirely
distinct diseases, and that their differences might be accounted
for by the dissimilarity of what they had to observe rather
than to errors of observation on either side. Now, pernicious
anaemia is, clinically, by far the most salient symptom of
anchylos tomiasis.
That the disease described by Malcolmson in Madras is
identical with that observed by Pekelharing in Achin is a
matter which hardly admits of doubt. Nothing can show
this better than to place side by side the cases and symptoms
recorded by the two authors. First, let us compare their
accounts of the symptoms in general. Malcolmson says—
" The disease presents such a variety of symptoms that it will be
more instructive to consider them in detail than to attempt any elaborate
general description. It will be sufficient to describe the most remarkable
characters.
" It usually commences gradually with a feeling of numbness, sense
of weight, and slight weakness and stiffness below the middle of the thighs,
sometimes preceded by muscular pains. There is slight oedema of the
feet and legs, especially along the tibiæ, often found to come on after the
other symptoms. The walk is unsteady and tottering, even when the
patient is not aware of weakness in the limbs, which are occasionally
tremulous ; spasms occur in the calves and soles of the feet, sometimes
becoming general and occasionally shooting to the chest and larynx,
obstructing respiration and speech. The want of power often rapidly
increases to almost total palsy, especially of the extensor muscles, and in
a few cases, the patient, after slight indisposition, suddenly loses the use
of his legs. Rigidity and various painful affections of the nerves accompany
the paralytic symptoms, and there is sometimes pain along the spine,
commonly at the two last lumbar vertebræ. In some cases the disease
goes no further, and a cure is effected ; but more frequently. the numbness
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agreed as to its depending primarily on nervous lesions. The
comparatively rude methods of clinical and pathological
investigation available fifty years ago naturally prevented
Malcolmson's recognizing the peripheral origin of these lesions,
but he describes clearly enough, from advanced cases, lesions
of the spinal cord and larger nerves, which we know now to
be of a secondary character, and entirely similar to the
advanced lesions described by Pekelharing. Compare, too,
the following two cases, extracted, almost at random, one
from each author.
The case I extract from Malcolmson is reported as
follows:—
" James Hicks. Indo-Briton, April 24th, for sometime ill of beri-beri;
limbs cold, moist, and numb ; oedema of back and legs, partial loss
of power of lower extremities ; tendons in hams sometimes contracted,
and legs are extended with difficulty ; spasms of calves ; urine pale, depositing
earthy phosphates. 26th.— Heat of feet nearly restored ; numbness much the
same. 27th—Feet mostly warm, when they sweat they get cold. May 4th—
Less numbness, and cannot bear the heat of sand in which he has been
walking at noon for some days ; coldness of toes and heels only, cold sweat
of forehead. 19th—Legs to-day cold and covered with sweats. Vespcre.
Skin very hot all day. Pulse 100. Thermometer in axilla and palms
of hands 101°; between soles of feet, which, like the rest of the benumbed
parts, do not feel hot, 77°, and above the knees a little higher. Temperature
of the air 89°. Barometer 30'. 20th.—Fever left with sweating. Temperature
of axilla and hands 9B J , feet 91°, and says they are not so cold as before.
Temperature of the atmostphcre 86°, Barometer 29' 58". Hardness of the
flesh over the lower part of calves, and a cold sweating covers the part.
Internal feeling of heat in right leg. Says the 'veins are now getting a
colour from the blood, and that before they were empty.' After this,
while the temperature of the air varied from 89° to 93° (Barometer 29'
48"), the feet were of the same temperature as the air, and the hands 97,°' but
when that of the air fell to 83° and it was loaded with sensible moisture,
the feet were at 87° and the hands at 94°. The numbness wns not
complete, and slight oedema extended apparently into the interstices of
the muscles. In the progress of the case, burning sensations in the feet and
calves of legs came on, bat the surgeon into whoso care he passed did not
ascertain the temperature. The arterial action did not seem to have been
weakened in the cold parts, but the colour of the blood in the veins, as far
as could be judged from that of the vessels, was not of the usual dark
hue."
The case extracted from Pekelharing is that reported on
page 23 of his paper :—
" Mang, aged apparently about 21, born at Batavia, has served for four
months as a sailor 011 board the Hydroyraaf, off the island of Onrust.
There were several cases of beri-beri on board. He had never been ill
before. According to his own account, which there is no reason to doubt,
he became ill on 4th December 1887. In a few days his legs became
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doubt, after reading the above extracts, that both authors are
describing the same disease.
Now, this epidemic affection of the nervous system presents
not the least similarity with anything met with in Assam.
Compare these accounts with the symptoms of anchylostomiasis
as given in Dr. Kynsey's pamphlet (page 5, paragraph 26),
which, being readily accessible to all interested in the diseases
of Assam, I will not occupy unnecessary space by extracting.
In the one disease the prominent character is paresis, and
anæmia is an after and unessential complication ; in the other,
the leading symptom is anæmia, and no true paralysis ever
occurs.
Seeing then the confusion that has been caused by the
use of the word, and the fact that it has nowhere any ver-
nacular signification for the patient affected, but is used only
by Europeans, it would, I think, be in every way preferable
to entirely drop the use of the word and to adopt some
such words as anchylostomiasis or parasitic anæmia for the
beri-beri of Ceylon and Assam, and specific peripheral neuri-
tis, or endemic palsy for the disease described by Malcolmson
and Pekelharing in Madras and Achin respectively.
Before closing these introductory remarks, I would wish
to point out that, situated as I am at the time of writing, far
from all medical libraries, it is quite impossible for me to do
justice to those who have worked at the question before me, or
to attempt to give any bibliographical references whatever.
I have not even been able to gain access to Leich-
tenstern's paper, briefly referred to in Dr. Kynsey's compila-
tion, though it is possible that he may have followed the
rhabdites already described by many previous observers to the
adult condition, in which case much of my work may have
been forestalled by him. However, not having seen the paper,
it was necessary to work out the whole question anew, and
I am necessarily ignorant of how far his results go, or to what
extent they coincide with my own. There must, however, be
some mistake in either the original paper or its translation.
The paragraph to which I refer is to be found near the bottom
of page 52 of Dr. Kynsey's pamphlet, and is worded as
follows :—
" The work of Leichenstern announces the discovery of a rhabditic
form, the segments of which have an independent life when separated, and
are able to propagate the species."
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Now, to speak of the "segments" of a nematode worm,
which is not a segmented animal in either the biological or the
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popular sense of the word, is a zoological absurdity, as egre-
gious as would be the description of a vertebrated molusc or
an eight-legged insect. The description would apply well
enough to a tapeworm, although it would hardly be, strictly
speaking, correct to speak of the proglottides of a cestode as
" segments," a term which, in biology, is properly restricted to
the externally visible somites of arthropods, but, taken as it
stands, the statement is utterly unintelligible. If we substitute
the word " individuals " for " segments," and strike out the
words " when separated " altogether, it becomes not only
intelligible, but in accordance with the facts of the case as
I have observed them ; but it is difficult to understand
how even the most careless translator could make such a
combination of mistakes, unless, indeed, he mistranslated the
word corresponding to " segments " and, on. his own authority,
inserted the words " when separated " in order to explain it.
On this account I have been much disappointed that, up
to date, my correspondent in England has not forwarded me
the original paper. It is, of course, possible that the note in
question may be a translation of an abstract originally made
by an unskilled hand, or may even have passed through
several hands before assuming its present form, but, in the
absence of the original, it is difficult to say where the very
obvious errors took their origin.
Before coming to Assam, I took the opportunity of search-
ing for references to beri-beri and anchylostoiasis in a file
of the Medical Record, but came across very few. Those that
I found referred -exclusively to cases of beri-beri., which come
under the heading of endemic peripheral neuritis. My file did
not, however, extend back for more than a few years.
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II.—THE GENErAL CourSE AND RESULTS OF THE INVESTIGATION.
Leaving the Central Provinces on the 1st November 1889,
Calcutta was reached on the 4th, Though well provided with
microscopes and microscopical accessories, I possessed 110
bacteriological plant, apparatus of this kind being too bulky
to form part of the kit of a medical officer engaged in his
usual routine work.
In view of the fact that the cause of kála-azár was quite
unknown while the researches of Pekelharing and others
indicated a bacterial origin, for beri-beri, it was clearly
necessary to be provided with sufficient bacteriological
apparatus to start laboratory work of that kind. I accord-
ingly obtained permission from Deputy-Surgeon-General C.
P. Costello, F.R.C.S., Sanitary Commissioner of Assam, to halt
a sufficient time in Calcutta to procure what might be neces-
sary. Apparatus of this kind is of course not kept in the
very limited stocks of the purveyors of scientific appliances
in any Indian town, so that it was necessary to get many of
the requirements made, and some other articles, through the
kindness of the Superintendent, Dr. Wood-Mason, were pur-
chased from the Laboratory of the Indian Museum. I also chose
at the Telegraph Maintenance Company's establishment a medi-
cal battery, in case I should afterwards require one. The
disease observed by Pekelharing in A chin depends essentially
upon nerve lesions, and for its investigation electrical appara-
tus is absolutely necessary ; but, from what I had already read,
it appeared tolerably certain that the disease described by
him was quite distinct from that known by the same name
in Ceylon and Assam, so that in all probability it
would be unnecessary to spend Government money in
the purchase of one. As, however, in no instance have
cases been met with exhibiting symptoms pointing in
any way to nervous lesions, it has never been necessary
to buy the apparatus chosen. While such of the articles
were being made as required personal supervision, I
employed myself in preparing a stock of tubes of culti-
vating media, which I was enabled to do much more
quickly and easily in Calcutta than could have been done
elsewhere, because there, by the courteous permission of Dr.
Warden, the Chemical Examiner to Government, the resources
of the well-equipped laboratory of the Medical College were
entirely at my disposal.
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Owing to the unavoidable delay so caused, it was not
until late in November that I reached Gauháti, which had been
indicated as the best point from whence to commence
operations. Here I found a most zealous and obliging
coadjutor in the person of Dr. Mullane, the Civil Surgeon,
who not only set aside for my use a room in the dispensary,
but found accommodation in his house for myself and labora-
tory, but for which, owing to the entire absence of other
suitable accommodation, it would have been very difficult to
proceed with the work at all. There were five or six in-
patients in the dispensary suffering from kála-azár, as well as
a daily casual attendance of out-patients suffering from the
disease, and the first step was clearly to make a careful exami-
nation of the cases at my disposal.
The greater number certainly presented more or less
prominent symptoms of malarial poisoning, but it was
equally apparent that, in by far the larger proportion, the
malarial symptoms were quite inadequate to account for
the gravity of the mischief. On casually enquiring the history
of a case, the patient would generally say that it had commenced
with " fever," and he had it off and on for months. On a more
and more close interrogation, however, so as to distinguish true
ague from other maladies, it generally came out that there had
been comparatively little true fever, and that what the patient
really meant was merely that he had been feeling ill for a long
time. There is of course nothing new in this, because every-
where in India, nearly all disease is ascribed by natives to
"fever," and it is only by the most patient enquiries as to the
exact symptoms actually experienced that one can get any other
history for nine diseases out of ten.
Then, again, most of the cases had more or less enlargement
of the spleen, many of them exhibiting a regular " ague cake ;"
but when we remember how rare it is in post mortem exami-
nations to find any Indian with a spleen of the normal weight,
it will readily be seen that too much importance should not
be attached to the presence of a symptom which is well nigh
universal, and is by no means incompatible with fair general
health. A much enlarged spleen may of course do damage
by its pressure on the other abdominal organs, but otherwise
it is important only as a sign of malarial poisoning. It is
that poisoning, and not the splenic enlargement caused by
it, that is the cause of malarial cachexia, for we know that the
spleen can be entirely removed without, to all appearance,
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affecting the general health. Hence it is a mistake to attach
any great importance to an enlarged spleen, unless its pre-
sence be accompanied by other symptoms of malaria. It is
a matter of common experience to find men doing their full
day's work, and quite healthy to casual examination, and yet
having a spleen so large that it may extend down to the iliac
bone and across the middle line. Such subjects are in con-
stant danger of death from rupture of the organ, caused by
comparatively slight injuries, but otherwise do not appear
much worse off than their fellows. Indeed, spleens as large as
this may be found hidden under the folds of fat covering sturdy
Banniahs, whom no one would consider cachectic.
Now, the cases in the dispensary, though in a terrible state
of cachexia, gave no other evidence of malarial poisoning
than a very variable amount of splenic enlargement. The
temperature charts, far from forming the well-known malarial
trace, exhibited, as their most marked character, a subnormal
temperature, indicative of a profound depression of the vital
forces. At first I could not, and would not, believe the ther-
mometric observations to be correct, but repeated and care-
ful observations with several thermometers which were tested
by comparison with thoroughly reliable instruments of non-
clinical make, showed that this low temperature was an actual
fact in all advanced cases.
I have observed the temperature as low as 94°F., and this
in cases by no means absolutely dying. A temperature of
95° rising to 96° in the afternoon was often persistent for
several days together ; such low temperatures are almost un-
known except in the case of profound traumatic shock or in
articulo mortis, and are certainly unknown to persist for any
length of time in any other disease than anchylostomiasis.
This and the profound anæmia were the most marked clinical
characteristics of the disease with which I had to deal.
Putting aside cases of ordinary sickness of all sorts,
which were freely brought me as kála-azár, this anæmia was
the one constant symptom. As has been repeatedly noted
by previous observers of kála-azár, it is the earliest symptom
to appear, and its intensity advances pari passu with the
disease. Its characteristics easily distinguish it from the
anæmia that accompanies malarial cachexia. In the latter,
anæmia is a late and secondary symptom, whereas here it