NationalLibraryOfScotland/medical-history-of-british-india huggingface dataset:
( 34 )
Results of Analyses of Specimens of Water from
Name of place.
Backwater of Brahmaputra at
Chowdoniah.
Well, Pykan, Salpara outpost
Banishpara well, Goálpára police
hát
Label illegible
Well, Darrangiri, Ranguli outpost
Label partly illegible, Bijni out-
post, well water.
Ditto
Well, Chihari village, Ranguli
outpost.
Well, Kota Kuti village, Punjab
outpost.
Lakhipur (" Radha para " well) ...
Chigknagoal
„ coolie depot
.
Katalgouri Tea-garden kacha well..
Smell.
Faint.
Slight ...
Disagree-
ble.
Horribly
foul.
Faint ...
Nil.
Slight ...
Nil.
Slight ...
„ .......
Hardly any
Slight ...
„ .......
Distinct ..
Foul ...
Nil.
Bad
...
Nil.
Colour.
Fair
Brownish...
Rather brown
Good ...
Fair ...
Good ...
Fair ...
Brownish ...
Good ...
„
.......
Fair
Brownish ...
Brown
...
Fair
Re-action.
Acid
Alkaline ...
Acid
u
Neutral ...
Slightly acid
Acid
Slightly acid
Markedly
acid.
Ditto ...
Acid ...
Neutral ...
Acid ...
„ .......
„ .......
Acid
...
1·0
0·6
4·0
3'0
1·6
1·4
1·2
1·0
1·6
0·4
2·2
2·45
1·5
3
1·5
5·0
0·5
0·3
0·4
0·9
0·8
07
6·8
1·1
0·6
2·2
2·4
1·7
1·3
2·0
1·0
0·8
1·3
4·4
...
...
( 35 )
places affected with Kála·azár and Beri·beri.
3·0
2·1
12·2
4·2
2·1
10·3
1·6
0·7
2·8
2·3
2·4
1·6
3·5
5·8
3·5
Ammonia by
Nestless test
qualitative.
Slight trace
Ditto
Strong re-action.
Very marked re-
action.
A truce
..
Distinct re-action
Marked re-action
Distinct re-
action.
A trace
Marked re-action
A trace
Ditto
Ditto
Distinct re-
action.
Marked ditto ...
Strong ditto ...
Distinct ditto ...
Slight ditto ...
Miscroscopical appearance, &c.
Moderately abundant sediment consisting almost
entirely of fine sand, with a little decomposed
vegetable matter.
Scanty sediment, mainly decomposed vegetable
matter; diutoms, desmids, and other algse very
abundant.
Scanty sediment mainly inorganic, with some
decomposed vegetable matter.
Copious sediment of tenacious clayey matter,
containing much decomposed matter, vegetable
and animal; desmids, copepods, fibres, and other
evidences of pollution.
Scanty sediment of inorganic matter, mixed with
decomposed vegetable matter, copepods, amoebae.
Small amount sediment, mainly inorganic, with
some decomposed vegetable matter, algae, &c.
Scanty sediment, mainly inorganic, int'usorians ;
an ovum (not of any known human parasite,
but probably nenuitode.)
Scanty sediment, m:unly decomposed vegetable
matter, large numbers of infusoria and diatoms.
Scanty sediment, mostly inorganic, with a few
copepods and diatoms.
Scanty sediment, almost entirely decomposed
vegetable matter, containing infusoria, with fibres,
and other evidences of pollution.
Much sediment; decomposed vegetable matter
mixed with fine sandy particles, infusoria, cotton
fibres, and evidences of pollution.
Scanty flocculent sediment consisting entirely of
zooglcoa entangling grains o£ rather coarse
sand. The zoogkea has probably developed since
the collection of the specimen.
Scanty sediment, mainly inorganic, diatoms, des-
mids, &c.
Consideratilo sediment, mainly decomposed vege-
table matter.
Much sediment, clayey matter, with evidences of
human pollution.
Very scanty sediment, consisting almost entirely
of fibres, particles of rice husk, &c., looking in
fact as if a pinch of house dust had been added
to the water.
Of the same character as above.
Diito
ditto.
Ditto
ditto but in addition a specimen
of a rhubditis, possibly dochniius, was found.
Quality.
Good.
Ditto.
Fair.
Very bad.
Doubtful.
Good.
Doubtful.
Bad.
Fair.
Ditto.
Doubtful.
Good.
Fair.
Doubtful.
Very bad.
D 2
( 3 ( ; )
Result of Annlyses of Supcimens of Water from
Name of place.
Nágaghooli tea-garden No. 2 coolie
lines.
Nágaghooli tea-garden No. 3 coolie
lines.
Hililika tea-garden, Bengali lines ...
,,
hospital
„
„
jungle lines, 3...
,,
new lines, 3
Talap tea-garden, Poolibari lines
well.
,,
Dhaniijori lines
2nd well.
,,
„
northern side
well, old lines.
„
„
northern side
well, new lines.
Talap new lines, southern side well
Bisakopi tea-garden, Buch well
No. 2 lines.
,,
,,
Pipc·w e 11
No 3 lines.
„
„
Jungle
side well No. 6 lines.
„
„
Big well
No. 6 Hues.
„
„
well No. 7
lines.
»
„
No. 9
lines.
„
,,
No. 2 lines.
„
tou.-house well
Smell.
Nil.
Foul
Nil
Faint
Disagree-
able
Nil
Colour.
Fair
"
...
Good
»
Fair
Good
π
υ
Fair
Good
Deep brown
Fair
Good
»
Slight
Pale brown
Slight
Fair
Slight
Re·action.
Faintly acid.
Nil
Faintly
acid.
Dilto
Ditto
Acid
Fa i n t 1 y
acid.
Ditto
Nil
Disii η ctl y
acid,
Faintly
acid.
Acid
F a i η t 1 y
acid.
D i s tinctly
acid.
Nil
Acid
Nil
Faintly
acid.
Nil
Dietin c 1 1 y
aoid.
3·3
4·1
2·1
1·2
4·1
2·3
1·4
0·9
5·3
7·4
37
1·1
3·7
1·7
3·1
0·9
1·0
1·4
0·5
1·4
0·8
2·2
0·4
0·4
2·0
3·6
08
0·4
0·4
0·4
0·4
5·4
0·4
0·7
1·0
0·4
1·0
04
0·3
0·5
( 87 )
places affected with kála·azár and Beri·beri.
5·1
3·8
3·5
35
3·2
3·5
3·8
28
fi 3
5·3
4·9
3·8
6·3
3·8
4·0
3·5
3·5
2·8
3·1
4·5
Ammonia by
Kestlfss test,
qimiiuttive.
Faint re·action ..
Strong
Ditto
Distinct
Nil.
Nil.
Ditto
Ditto
Doubtful
Distinct .........
Marked
Slight
Nil
Trace....,
Trace
Distinct
...
Ditto
Miscroscopical appearance, &c.
A copious brown sediment, consisting mainly of
clayey matter, with eoino decomposed vegetable
debris, infusoria, &c.
A moderate amount of floculent sediment, almost
purely organic and showing plain evidences of
human pollution. Some large ova, possibly
trematode.
Scanty brown sediment, consisting almost entirely
of decomposed vegetable matter.
Sediment somewhat less copious, but otherwise of
the same character as the preceding.
A moderately copious sediment, almost entirely
decomposed vegetable matter, but showing some
evidences of pollution.
Sediment less copious, but otherwise of the same
character as the preceding ; monads.
Scanty brown edimont, mostly decomposed vegeta-
ble matter, insect larvai, monads, and inf'usoriuns.
Very scanty sediment, mainly vegetable matter ;
but fibres, &c.. of suspicious character.
A very scanty brown stdnuent, consisting almost
entirely of decomposed vegetable matter.
A very scanty sediment, consisting almost entirely
of fine sand, with a little decomposed vegetable
matter.
A very small sediment, mainly inorganic, with
some decomposed vegetable matter.
Colour too brown for reliable NH 3 determination.
A copious dark red peaty deposit consisting
mainly of decomposed vegetable matter, and
containing filamentous algse, copepods, &G.
Copious orange-coloured sediment, consisting
almost entirely of an oval bacterium.
A scanty dark brown sediment, consisting of little
else than decomposed vegetable matter.
An exceptionally small sediment of the same
character as the preceding.
Scanty greenish sediment of the same general
character as the preceding, but with some doubt-
ful evidences of pollution.
A very small black sediment, consisting entirely of
living and dead vegetable matter.
Scanty brown sediment consisting of clayey matter,
filamentous algae, &c.
An exceptionally small, flocculent sediment, consist-
ing entirely of living and dead vegetable matter.
Scanty sediment, consisting almost entirely of
filamentous algae.
Quality.
Fair.
Bad.
Good.
Ditto,
Bad.
Ditto.
Good.
Ditto.
Doubtful.
Ditto.
Good.
Bad.
Doubtful.
Fair.
Ditto.
Good.
Ditto.
V e r y
good.
Fair.
Ditto.
( 38 )
Nor are these by any means isolated instances. Far from
being so, cases such as that of Paru and Maligaon may be de-
scribed as typical of the distribution of the disease, especially
in the Chaygaon district, where the villages, though small, are
very numerous, and placed at small distances from each other.
In the earlier reports on the subject, and in support of
a malarial origin for the disease, much stress is laid on the
assumption that kála-azár is necessarily a terai disease ; and, no
doubt, as long as the disease remained confined to the Gáro
terai, this was a fact, but the spread of the disease shows that
the connection, then so confidently asserted, was quite casual,
being merely due to the circumstance of the disease, at that
time, not having spread beyond the terai regions. Now, how-
ever, the disease is common in portions of the Province which
are in no sense terai, and as far distant from the hills as any
portion of Assam can be. For example, the Chaygaon thána
is now the portion of Kámrúp most seriously affected, and the
disease is as rife there as anywhere in the Province, so
much so, indeed, that it was at once suggested as the most
favourable centre for my enquiries ; yet this very region
was, previously to the appearance of kála-azár, considered
the most salubrious portion of the district. Commenting
on the comparative immunity from cholera enjoyed by the
thána during the year 1882, Dr. Eussell, the then Civil
Surgeon, remarks :—
" Its natural features should make Chaygaon thána the healthiest
region of the district. Its southern portion consists of hills and highlands,
timber covered, and well watered by hill streams (bra.ncbes of the Singra
and Kulsi rivers). Its northern half, though lying low, and containing a
large extent of swamp, yet is well tapped by watercourses, and consequent-
ly fairly well drained. It is rarely subject to inundations, and, if these
occur, they quickly subside."
Nor is Dr. Eussell alone in his opinion, for Dr. Mullane,
in his annual report for 1884, remarks in much the same
terms on the comparatively greater healthiness of the Chay-
gaon thána over the rest of the Kámrúp district. Added to
this, by far the greater part of the population live far from
hilly or terai portion of the thána, and are so closely settled
that the land is almost continuously under cultivation, and
exceptionally open and free from jungle. If malaria be the
source of kála-azár, how is it that a district possessing such
comparatively favourable features should be now devastated
by the latter disease, while many truly terai portions of
Kámrúp remain untouched. It will be thus seen that the
( 39 )
facts relating to the spread and distribution of the disease
are entirely at variance with a malarial origin.
In connection with the spread of the disease, another
point remains to be considered, and this is the strong popu-
lar belief in its contagiousness. This belief is founded on
the undisputed fact that, when once a case of kála-azár
has appeared in a village, others soon appear, or, in other
words, that the disease appears to spread. Moreover, this
tendency is especially often noticed in members of the same
household, who, one after another, contract the disease until
occasionally all may fall victims to it. So far as I know, no
one has ever disputed that such are the facts of the case, and
during my enquiries I found that if one person in a family
was affected, it was common to find that many other members
would be found in various stages of the disease ; while other large
families remained quite free from the disease, though living in
a badly-stricken village. Now, these facts certainly point
strongly to contagion. They may, or may not, be capable of
some other explanation, but in the face of their admitted
genuineness, it appears to me quite unjustifiable to state, as is
done in so many reports, "There is not a particle of evi-
dence in favour of contagion." Nearly all the reports I have
read confidently assert that there is no evidence to support
the popular view ; but it is evident, on reading them, that
the conclusion has been based rather upon a systematic
ignoring the facts of the case than upon a patient consideration
of them. Dr. P. M. Gupta, for example, in his report on the
Gáro Hills for the year 1888, says :—
"The belief that it is contagious is founded in the fact that when one
is seized with an attack of this fever in a village, there are others soon to
follow" (the italics are mine) ; " hut this is no doubt due to the same climatic
influences under which they all live ; and that the fever ceases to be less
virulent, and less liable to attack others when the inhabitants shift from one
village to another" ( as they not unfrequently do when this disease is very
bad amongst them), "only goes to prove my contention" (of a malarial origin)
"beyond doubt."
I select this report because it contains, in a few words,
the leading arguments, over and over again repeated, in
other reports, as to the malarial origin of Kála-azár.
The second sentence is somewhat involved, but I take the
writer to mean that removal from an infected site is effica-
cious in checking the spread of the disease.
It is perfectly obvious that the facts, which are admitted
by the writer, really warrant quite the opposite conclusion.
( 40 )
It is perfectly clear that, from the nature of the case, in all
instances of communication of disease from man, to man the
subjects must be under the " same climatic influences," and that
the argument might be applied with equal cogency to small-
pox, or any other admittedly infectious disorder. If, moreover,
these outbreaks of kála-azár in villages be due to climatic in-
fluences, it is clear that the outbreak should attack a large
number of people simultan'eously, or nearly so, whereas, instead
of this, we find that the disease always attacks but few of the
inhabitants of a village at first, and then spreads with excep-
tional slowness. Accompanied, as it is among the Gáros, by
desertion of the sick, it is obvious that migration is a most
efficient measure in the case of any communicable disease,
whereas the breaking up of new ground would, as is well known,
teiid to intensify malaria instead of checking its ravages, so much
so, indeed, that other writers have, on this very ground, advanced
the migratory habits of the Gáros as one of the causes of kála-
azár, so that while one observer points out that migration
checks the disease, another gives it as one of its causes, both,
in different ways, twisting the facts to support a connection,
between kála-azár and malaria.
If analyzed, all the arguments in favour of malarial - origin
amount to this. kála-azár closely resembles malarial cachexia.
Therefore they are identical. Malaria is not contagious.
Therefore all facts that point to contagion must have some
other explanation; which, as will be seen, is bat arguing
in a circle.
It is never safe to entirely ignore a widely-spread
popular conviction of this kind, and I know of no instance of
a disease popularly believed to be communicable ultimately
proving to be otherwise, for the popular mind is much more
apt to overlook contagion than to believe in it. Ten years
ago, the medical profession were practically unanimous on the
belief that tuberculosis was never contagious, and this in spite
of a strong popular impression to the contrary. Yet, quite
recently, the communicability of tubercular phthisis has
become an established fact, and the methods and vehicles of
communication have been clearly made out. As will be seen,
when the method of transmission of anchylostomiasis is dis-
cussed, the fact that migration accompanied with desertion of
the sick is efficacious in checking kála-azár entirely fits in
with the facts relating to the method of communication of this
parasitic disease, and is a strong argument in favour of their
identity. Indeed, if the arrangements for excluding the
( 41 )
sick could be made thorough, it would be absolutely
effectual, and the reason why Kála-azár often springs up
again amongst the migrated community is because the
advance of the diseases is so insidious, that they necessarily
included among their number many infected, but unsuspected
persons.
Another point in connection with the spread of kála-
azár is that there is no recorded or even hearsay instance
of an European becoming infected. Europeans, of course,
suffer much less than natives from malarial cachexia,
but they nevertheless enjoy no complete immunity from
it. The number of Europeans living in the affected districts is,
it is true, but small, but, in spite of their small number.,
their escape would be indeed remarkable if malarial in-
fluences were abroad sufficient to account for the terrible
ravages of kála-azár. For these Europeans were certainly
exposed to the same climatic influences, and the conclusion
seems inevitable that, as their climatic surroundings were
the same, the source of their immunity is to be found in
a difference of habits, and, be it observed, that it is only
among such Europeans whose habits assimilate them to the
semi-civilized inhabitants of Assam that anchylostomiasis has
ever spread. It is only among the lowest class of miners and
brick-makers that the disease has been ever known in Europe,
never among the class who migrate to Assam to serve as
officials, tea-planters, and missionaries.
E
( 42 )
V.—THE SYMPTOMS OF " KÁLA-AZÁR " AS ILLUSTRATED BY
CASES.
What then is kála-azár ?
The best method of answering this question will be to
give the notes of a number of cases, as described by
different observers, commenting on whatever may appear
most remarkable in each or all.
I will first quote some cases described by Dr. Dobson,
Civil Surgeon of Goálpára, in a special report on kála-azár,
furnished by him, when the disease first reached an epidemic
importance in that district. These cases are convenient for
our purpose, because, while occupying but little space,
whatever is recorded is so much to the point, that it is
generally easy to make a diagnosis of the true nature of each
case, and they illustrate, in a most typical manner, the sort of
cases that are brought to one, when visiting a kála-azár-
stricken village.
That Dr. Dobson did not then recognise the greater
proportion of them as instances of anchylostomiasis is due
to the fact that the disease is one which is never encountered
in English medical practice, and that for this reason we
are at the best familiar with it only by occasional extracts
from the foreign medical press. At the date of Dr. Dobson's
report, the connection between the anæmia of coolies and
anchylostomiasis was not even suspected. I had the pleasure
of many discussions with Dr. Dobson during my stay at Dhubri
in March last, and, since then, he has made renewed obser-
vations on the subject, and appears to have come to much
the same conclusion that I have, for while "opposed to
admitting all kála-azár is anchylostomiasis," in his remarks
on the Damra Charitable Dispensary he says "I have no
doubt many of the so-called cases of Μία-azar are cases
of anchylostomiasis;" and notes, too, that malarial cachexia
and anchylostomiasis appear to complicate each other in
Damra, which is entirely in accordance with my own
observations elsewhere. This, it appears to me, is as near
a coincidence of opinion as can be expected so shortly
after the promulgation of my views in the preliminary note
appended to last year's Sanitary Report, and I feel sure
that a few more visits to kála-azár-stricken districts will
bring Dr, Dobson's views into entire accordance with my
own.
That people brought low by anchylostomiasis should more
( 43 )
readily become the subjects of malarial poisoning is only natur-
al, and a very large proportion of cases undoubtedly do present
this complication ; but, apart from some amount of increase on
this score, I see no reason for believing that malarial cachexia
is commoner now than it always has been. From first to last,
as much before kala-azar was heard of as after, the ravages of
malarial poisoning form a prominent subject of annual and
other reports. Indeed, the malariousness of Assam is notorious
now, and always has been, so that it would be indeed astonishing
if kala-azar cases failed to present this complication.
Case No. 1 " was that of a Gáro woman, who had been
ill for over a year. It had begun with strong fever. She had
tried village medicines, which consisted of leaves mixed with
mud; but as she got worse and emaciated, she was told she had
"kala-azar" and nothing further was done for her. When seen
by me, she had a temperature 103° F. ; she had a troublesome
cough, with little or no expectoration, dullness over both lungs,
especially about their apices, and all the physical signs of phthi-
sis were present. Her pulse 65, and very weak ; her tongue pale,
conjunctivæ deadly white; eyes far sunk in their sockets ; cheek-
bones prominent, cheeks hollow. Appetite almost nil. She was
so weak that she could not sit up, and, when raised, we had to
put her down. Her spleen and liver were not enlarged : if any-
thing, they may have been slightly atrophied. She was passing
her stools involuntarily, and had done so for four or five days.
There was no dropsy or oedema of any kind present, nor could
I learn that she ever had either. Such then was a case of kala-
azár, but which was in reality a typical case of phthisis. The
woman's complexion was of the ordinary brownish colour. No
one would come near her, she was alone in a miserable hut,
which was tumbling down. Her food and drink were handed
in at the door, none of the villagers would touch her : even her
husband had taken another house in the village, and the
children (varying in ages from three to seven) called out to the
Hospital-Assistant and myself, and warned us not to touch her:
when they found we had, they immediately called out ' you
will get kala-azár.'
"This is the popular idea among the Gáros, and it is one that
is early impressed on the young mind. The odour within this
poor woman's house was very trying. It was difficult to
get even these few particulars about her illness, as every one
shunned her: even these particulars, such as they are, must be
received with caution."
E 2
( 44 )
In this case the most prominent symptoms, at the time of
examination, were those of lung mischief. There can, how-
ever, be little doubt that the case was primarily one of anchy-
lostomiasis, low broncho-pneumonia, such as exists in one
form of phthisis, being one of the commonest terminations of
the disease, and actual phthisis a common complication.* It is
to be observed that there are no signs whatever of malarial
cachexia, neither spleen nor liver being enlarged.
Case No, 2 " was that of a very healthy-looking girl,
aged nine years, who was brought to me by her grandfather
saying she had káda azár. It seems she had fever a year
ago, which lasted for two or three months steadily, coming
on at evening usually. From the description given of it, it must
have been an ordinary case of quotidian ague. For the last
two months she had no more fever. Three months ago, for
about ten days, but at intervals of two or three days, her
nose bled, but to no great extent. At this time also she had
occasional attacks of diarrhœa. At present she is very well
nourished, with a good appetite, a clean tongue, no pains, no
pigmentary deposits of any kind ; her spleen extends down
to her groin, and her liver is also enlarged. She is toler-
ably dark in complexion. The grandfather is aware of her
enlarged spleen, and imagines she had kála azár, but does not
think she has become blacker than usual."
This is evidently a case of ordinary malarial fever of a
mild type. Observe that, in spite of very large spleen and
enlarged liver, her general health is comparatively little affected,
as so often happens in such cases, when tending to cure.
Case No. 3, " a Rabha man; fever for four months, which
comes on every third or fourth day. He had no fever when
I saw him. He is well nourished, but slightly anæemic. His
appetite is good. Spleen is slightly enlarged. He is darker-
skinned than most of his neighbours, but if anything slightly
clearer than his own brother, who is in good health. He has
been told he has kála-azár, but does not believe it, as he does
not think he is likely to die for some time to come. He
has never had diarrhoea or oedema of any part of his body."
Probably a case of early anchylostomiasis complicated
with malaria.
Cases Nos. 4, 5, and 6 " are those of a Kachári man
and his two sons, aged five and seven years. They have all
Vide Dr. Kinsey's pamphlet, already quoted, pages 52-53.