NationalLibraryOfScotland/medical-history-of-british-india huggingface dataset:
43
Suitable conditions for breeding were unlimited but fish of the genus
Haplochilus were very common and were found in all waters but those of a
very temporary nature.
61. The predominating type of parasite among the children in the villages
was simple tertian. Among convicts admitted to hospital and among the
convalescent gang quartan infections formed 50 per cent. or over. The carrier
was the same and there is little reason to doubt that the quartan parasite
predominated in the case of the labouring convicts because circumstances
favoured relapses whilst actual transmission of the disease was not very active.
It is interesting to note that though infection with malignant tertian at
the time of my visit was very little in evidence yet the only two infected
anopheles encountered were infected with this type of parasite.
62. There is some reason to believe that proportionate prevalence of the
different forms of parasites in any community is dependent upon—
( a ) A c t i v i t y o f t r a n s m i s s i o n ( n u m b e r s o f a n o p h e l e s c a r r i e r s ) ;
(b)Factors increasing or diminishing the number and continuance of
relapses.
Malignant tertian (producing gametes) most abundantly increases
whenever transmission is active, i.e ., the numbers of anopheles are high. Quartan,
producing few gametes but peculiarly prone to relapse and to remain for long
periods in the blood, relatively increases when transmission is low but factors
favouring relapses high. Simple tertian is an intermediate form able to assert
itself most when transmission is moderate and. the antagonism to relapses not too
high (native children as against well fed Europeans who surfer most from
malignant tertian due to fresh infection).
It remains to be seen whether the frequency of relapses at different periods
after the original infection does not differ in the case of different parasites, still
further enabling us to explain the prevalence of different species of parasite
under any given conditions.
MALARIA AMONG THE LABOURING CONVICTS.
63. In spite of the moderate endemicity of malaria in the Andamans the
labouring convicts suffer greatly from malaria. This high prevalence of the
disease is chiefly displayed in mild and frequent attacks associated with a good
deal of chronic ill-health of an indeterminate kind. It is very probably that
much of this is the result of relapses, not as a rule re-infection.
64. There is a fever season during which the admission rate reaches from
2 to 4 times that present in the healthier season. This season corresponds
almost exactly in its onset with that of the rains. It appears to be an almost
G 2
44
exact parallel to the conditions at Panama which Deeks and James explain by
ascribing the fever season mainly to relapses.
65. The direct effect of malaria on the death rate as shown in the returns
is small. The bulk of the deaths are due in order of frequency to phthisis,
dysentery, and pneumonia. Pneumonia is definitely associated with malarial
infection and its incidence among the convicts in the unhealthier western
district assumes especial importance.
66. Any relation of malaria to phthisis and dysentery is not easily traced.
It is possible that the same causes which lead to a high prevalence of these
diseases are also at work in increasing the prevalence of malaria. (Mental
effect of transportation, etc.)
67. Under the conditions present among the labouring convicts (moderate
fresh infection with a high prevalence of relapses and. continued infection)
everything relating to food, clothing, shelter and the conditions of labour are
of immense importance.
68. So far I was able to judge the care taken of the convicts and the
amount of thought and care expended upon their proper feeding, etc., is very
noticeable. Also the medical arrangements are excellent. If improvements are
possible in these matters they are of a kind that can only be brought about as
the result of careful scientific investigation of details as they affect in dividual
convicts. ( Vide Report by Dr. Bentley and. myself on conditions among
labour on tea gardens).
69. The treatment of cases of malaria in hospital for malaria is nevertheless
deficient. This is partly due to the short periods of detention in hospital and
partly to the absence of a policy of thorough and effective treatment of all
admissions for fever, a policy the rationale of which depends upon the relative
importanc e of relapses and fresh infections among this community. The
relative importance of relapses has b een clearly shown in this report. It has
also on general grounds been previously pointed out by Major Waters. 9
IX.—Recommendations.
SELF-SUPPORTERS AND FREE POPULATION.
70. In regard to many of the villages occupied by self-supporters and free
settlers very little action from the point of view of malaria is required.
Where a village is malarious there is no doubt that the proper procedure is
to move it either at once or gradually to a malaria free site. This has in
some cases actually been done in the past, e.g Namunagahr, a village formerly
situated. close by a swamp but now on an elevated site some distance from
the old one.
45
Since the inhabitants are directly under the orders of Government (there
are no very malarious free villages) the only difficulty is that of arranging for
cultivable land. In this respect the further opening up of areas in the direction
of Templegunj where malaria is at a minimum, would seen to be a very desir-
able procedure. Such an extension has been already foreshadowed in the Lyall
and Lethbridge Report on the working of the Penal Settlement of Port Blair.'
In this report, dated 1890, Major Lethbridge says :
—
"Hitherto the smaller Islands and the coast have been supposed to be the
most salubrious parts of the settlement, but from what I saw of the appearance
of the self-supporters in Hobdaypur, Tusanabad and even in the newly cleared
location of Cadellgunj, I came to the conclusion that it is more than probable
that the stations in the interior after they have been cleared and occupied for
some time will be found more uniformly healthy. Information on this point
will be very valuable and should be obtained without delay."
Now that the reason for this greater healthiness of the inland areas is clear,
it is even more desirable that such a unique opportunity as the possibility of
malaria free sites should, where possible, be made use of. Even without going
so far afield, it may often be possible by giving consideration to the habits of
. Nsm,. ludlowi and the known facts regarding the distribution of malaria in the
Settlement, to choose sites altogether or relatively free from malaria.
The village of Port Mouat would seem to be one of the first requiring
action of this kind.
LABOURING CONVICTS.
71. The question of malaria among the labouring convicts is much more
difficult and it is necessary to consider the matter from several standpoints.
72. Change of site of barracks .—It is obvious that to do away as far as
possible with chances of re-infection by moving stations to really healthy sites
rather than sites that simply appear salubrious would be an excellent step
where possible. Under conditions at the Settlement it is perhaps doubtful
whether any extensive movement of this kind could be made. Nevertheless
the site of some of the smaller stations where malaria is rife might be
arranged for. The removal of the station at Port Mouat, situated as it is a
few hundred yards only from the most malarious village in the Settlement, is
certainly called for. Before any such change is determined upon the most
exact observations should be made as to the conditions, and a limit of at least
half a mile from salt swamp or the coast made the first essential.
73, Anti-mosquito operations.—In most cases the treatment of salt swamps
would seem to be restricted to filling them up. In cases where the area to be
46
dealt with was small and close to important stations this might be undertaken.
Such a case might be the present Female Jail which is very malarious and.
situated near a comparatively small swamp. Whether the swamp should be
filled or the Jail moved would depend upon the relative cost of the two measures.
I was led to understand that it would be easier to move the Jail, but whether
this would actually be so or not I do not know.
Ordinarily the fact that most of the water of the Settlement is free from
larvæ, or very nearly so, and that the rainfall is heavy would make this method
of combating malaria in the Andamans not one to be recommended without
some special object in view.
74. Dietary .—As previously stated there is already in existence a very
carefully thought-out system for ensuring that as far as possible the convicts get
a good and sufficient dietary and that as much as possible is done to prevent
unnecessary hardship. But the immense importance of such matters under the
peculiar circumstances of this community make it desirable that improvement
in every possible detail should be energetically pushed and the importance of a
sufficient dietary above all never lost sight of. In this respect it is only fair to
mention that the Senior Medical Officer drew my attention to a number of
instances where improvement was under consideration, and that he had already
himself undertaken observations of the close and detailed character which alone
will enable true improvements to be instituted.
At present there is a system by which convicts after a certain number of
years instead of receiving cooked rations draw dry rations and make their own
arrangements.
During the short period of my stay which left me little leisure for such a
purpose, I was unable to investigate adequately the so-called " Talabwala system."
I gathered however that the actual working out of the system as it affected
convicts was much more complicated than appeared at first sight and it is very
desirable that its actual working should be very closely investigated so that the
system may be condemned altogether, modified, or exonerated from blame on a
real basis of knowledge. Most of those who have spoken about it to me
con-demned the system. It is possible, however, that it has certain good points even
if some of these are " irregularities. " Its greatest danger is not necessarily its
effect upon the Talabwala convict but that upon the whole community.
The most suitable type of barrack and details of administration do not
come within the scope of the present enquiry. From a malaria point of view
the most important considerations are the avoidance of cover for adult anopheles
by well-built, well-ventilated barracks thoroughly and frequently whitewashed.
In this respect the keeping of the interior, eaves, etc., whitewashed is probably a
measure of importance. To what extent " protection " is possible is doubtful.
47
75. Quinine prophylaxis and treatment. —As noted in Section VII the
effective treatment, and, as far as possible, cure of all cases of malaria admitted
to hospital has already been advocated. It is possible that in addition some
arrangement for the more general distribution of quinine on a sound basis
Could be instituted among those communities that are found especially infected.
The quartan parasite is very sensitive to quinine administered at the right
time. Moderate doses of quinine at frequent intervals would therefore seem to
be the form of administration indicated.
In conclusion I have to acknowledge the very substantial help given to me
by Major Woolley, I.M.S., the Senior Medical Officer of Port Blair and.
by others in the Settlement. I am especially indebted to Mr. A. Brown,
Divisional Officer of the Western District, whose constant help and assistance
enabled me to visit almost all the villages in the Settlement.
I am also indebted to Major L. Rogers, I.M.S., for very kindly furnishing
me with the abstracts of post-mortem records utilised in the section dealing
with the relation of pneumonia incidence to malaria.
48
References.
1. Brahmachari. .
. .
On an Anopheline allied to Myzomyia Listoni.
Indian Medical Gazette, July 1911.
2. Decks and James
.
.
Hæmoglobinuric Fever in the Canal Zone.
Isthmian Canal Commission, 1911.
3. Christophers and Bentley
. The Human Factor in Malaria.
Proceedings of the Bombay Medical Congress, Feb. 1909..
4. Mathis and Leger
.
.
Recherches de Parasitologie et de Pathologie humaines
et animales au Tonkin, Paris, 1911.
5. Marchiafava and Bignami . Twentieth Century Practice of Medicine, Vol. XIX,
1900, p. 74.
6. Stephens and Christophers . Relation of species of anopheles to malarial endemicity.
Reports to the Malaria Committee of the Royal Society,
Seventh Series.
7. James, W. M. .
.
.
Quartan Malaria and its Parasite.
Proceedings of the Canal Zone Medical Society, Vol.
III, April to Sept. 1910.
8. Marchiafava and Bignami . Twentieth Century Practice of Medicine, Vol. XIX,
1900, p. 142.
9. Waters
. . . .
Malaria as seen in the Andamans Penal Settlement.
Indian Medical Gazette, 1904, p. 419, also Lancet,
13 June 1903, p. 1657.
10. Lyall and Lethbridge . .
Report on the working of the Penal Settlement of Port.
Blair, 1890, p. 51.
SUPDT. GOVT. PRINTING INDIA, 8 HASTINGS STREET, CALCUTTA.
Photo-Engraved & Printed at the Offices of the Survey of India. Calcutta. 1912
Salt Swamp, Andamans. Home of Nyssomyzomyia ludlowi.
Herbertobad.
Anikhet
H o b d a y p u r
Mitha Kkari.
kadakachon's.
b i n r d r o b o n .
Templegunj
Cadellgunj
Manpur
V i l l a g e s
m t T u s o n
Tusonabad.
Healthy Andar Nomunagohy
Ogra Bayaj
Reg. No. 1633 E., 12.—H.—1,050.
MAP OF PORT BLAIR SETTLENENT.
No. 22.
( NEW SERIES. )
IP/QB, 10
SCIENTIFIC MEMOIRS
BY
OFFICERS OF THE MEDICAL AND SANITARY DEPARTMENTS
OF THE
GOVERNMENT OF INDIA.
MEDITERRANEAN FEVER IN INDIA: ISOLATION OF
THE MICROCOCCUS MELITENSIS.
BY
CAPTAIN GEORGE LAMB, M.D., I.M.S.
AND
ASSISTANT SURGEON M. KESAVA PAI, M.B., C.M. (Madras).
ISSUED UNDER THE AUTHORITY OF THE GOVERNMENT OF INDIA
BY THE SANITARY COMMISSIONER WITH THE GOVERNMENT
OF INDIA, SIMLA.
CALCUTTA:
OFFICE OF THE SUPERINTENDENT OF GOVERNMENT PRINTING, INDIA
.
1906.
Price ten annas or 1s.
No. 22.
(NEW SERIES. )
SCIENTIFIC MEMOIRS
BY
OFFICERS OF THE MEDICAL AND SANITARY DEPARTMENTS
OF THE
GOVERNMENT OF INDIA.
MEDITERRANEAN FEVER IN INDIA: ISOLATION OF
THE MICROCOCCUS MELITENSIS.
BY
CAPTAIN GEORGE LAMB, M.D., I.M.S.,
AND
ASSISTANT SURGEON M. KESAVA PAI, M.B., C.M. (Madras).
ISSUED UNDER THE AUTHORITY OF THE GOVERNMENT OF INDIA
BY THE SANITARY COMMISSIONER WITH THE GOVERNMENT
OF INDIA, SIMLA.
CALCUTTA:
OFFICE OF THE SUPERINTENDENT OF GOVERNMENT PRINTING, INDIA.
1906.
Agents for the Sale of Books published by the Superintendent of Government
Printing, India, Calcutta.
IN ENGLAND.
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& CO., LD., Bombay.
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ERNEST LEROUX, 28, Rue Bonaparte, Paris.
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A. M. & J. FERGUSON, Ceylon.
MEDITERRANEAN FEVER IN INDIA : ISOLATION OF
THE MICROCOCCUS MELITENSIS*,
S
INCE Wright's 1discovery in 1897 that the serum of patients who are
suffering from or who have recovered from Mediterranean fever has a specific
agglutinating reaction on M. Melitensis this method of diagnosis has been applied
to the elucidation of the continued Indian fevers. Thus Wright and Smith 2 have
tabulated 10 cases invalided from India, in which the serum gave a sedimenta-
tion reaction with M. Melitensis in dilutions ranging in most cases from 1 in 150
to 1 in 300. Many of these cases at the time of the examination presented
the usual sequelæ of the disease. At a later date 10 other examples were
observed by Birt and Lamb 3 in the Royal Victoria Hospital, Netley, in patients
who had been invalided for such diseases as malaria, typhoid fever and
rheumatism. It is worthy of remark that 14 out of the total of 20 cases thus
observed came from Mian Mir ; the other places where infection had occurred
were Calcutta, Sabathu and Nowshera.
In 1900 one 4 of us working in Bombay had the opportunity of studying
five cases of Mediterranean fever, which had evidently been contracted in
that city. These were cases of irregular fever without definite symptoms,
although marked sweating and pains in the joints were present in all instances.
A definite diagnosis was arrived at only by means of the serum agglutination
reaction.
A short time afterwards four cases were diagnosed in Simla.5All these
showed clear clinical symptoms and the sera of two of the patients gave positive
reactions with M. Melitensis. The sera of the other two cases were not examined.
In 1901 Greig 6 reported three cases of Mediterranean fever occurring in the
Swat valley. This diagnosis was reached by means of the serum agglutination
reaction, although the clinical symptoms were also very suggestive.
In 1904 Konrich, 7 working in Kolle's laboratory, made a series of agglutina-
tion experiments with M. Melitensis, which consisted in testing the agglutina-
tion and sedimentation reaction of seven strains of M. Melitensis with the sera
* This paper was received for publication on August 22nd, 1905.
2
of 17 men, many of whom had been treated with tuberculin. He records having
in some instances observed sedimentation in a dilution of 1 in 500 ; in dilution of
1 in 10 and 1 in20 nearly all gave complete sedimentation. It was also noted
that all the strains used did not give the same results, but that no difference was
observed between patients previously treated with tuberculin and those not so
treated. On this point Konrich's results are in direct opposition to those obtained
by Birt and Lamb,8 who in a series of over 150 controls found no sedimentation
in dilution above 1 in 10, and also to those of M. C. Nicolle, 9 who, after an
examination of the sera of 35 persons suffering from other diseases, concluded
that a complete reaction in dilution of 1 in 10 was strong evidence of the case
being one of Mediterranean fever.
Cornwall 1 0
examined the blood of nine healthy men and of nine cases of long-
continued, but ill-defined, fever which were clinically not characteristic of
Mediterranean fever, as regards their agglutination reaction with M. Melitensis.
He relates having got in some of these cases a complete or partial reaction in
dilution varying from 1 in 20 to 1 in 400, and concludes by saying "that even in
dilutions of 1—80 a complete agglutination of M. Melitensis is not pathognomonic
of Malta fever and that the blood of persons suffering from various febrile
conditions may have a higher agglutination power on the micrococcus than that
of persons in good health."
In spite, however, of the observations of Konrich and Cornwall we still hold,
that the serum agglutination method for the diagnosis of Mediterranean fever,
when properly and rigidly controlled, is one of the most delicate bacteriological
tests with which we are acquainted and ought to take its place as an important
addition to the ordinary clinical methods for the diagnosis of this disease. This
opinion is evidently shared by the Commission 11 for the investigation of Mediterra-
nean fever which is at present at work under the supervision of an Advisory
Committee of the Royal Society. A perusal of the first two parts of their report,
the only parts which have as yet appeared, will show the great use which these
workers make of this test both in the diagnosis of cases and as a means of
identifying the specific coccus. This opinion is strengthened by the result of
the investigations which we have now to bring forward.
These investigations are concerned with observations made on several cases of
continued fever in India, in which the diagnosis of Mediterranean fever was arrived
at by means of the serum sedimentation test. Further, in a considerable number
of these cases this diagnosis was proved to be correct by the isolation from the
spleen during life of a coccus bacteriologically indistinguishable from M. Melitensis.
As the preliminary step in all our cases consisted in testing the serum as regards
its agglutinin content, and as much reliance was placed on the serum reactions
of the specific organism when isolated from the spleen, it will be convenient
3
here, once and for all, to mention the technique employed and to state the pre-
cautions taken with a view to control these observations. All agglutination
experiments were made macroscopically in the capillary tubes devised by Wright, 1 2
by means of which also the serum dilutions were effected. Equal quantities of
the various dilutions of serum, made with normal salt solution, and of sterile
emulsions of the micrococcus were employed in all instances. The preparations
were allowed to stand at laboratory temperature (about 18° C.) for 24 hours,
when the results were recorded. The emulsions were all made in exactly the
same way, namely, an uniform growth on agar of from 4 to 7 days was emulsified
with sterile normal salt solution, about 2.5 cc. of the latter being used for each
agar culture ; the bacteria were then killed by heating at 60° C. for 15 minutes
and finally 0.5 per cent. carbolic acid was added.
During the period that the observations to be related anon were in progress
controls with the bloods of healthy individuals and of persons suffering from other
diseases were made almost daily. In this way an ample number of control ex-
periments were obtained both with the stock organism and with the several races
isolated from our cases. Thus, we tested as controls the following bloods :
—
(1) The bloods of 51 healthy individuals, all natives of India. —Of these,
11 were servants at the Pasteur Institute and 40 were persons who were under-
going inoculation against rabies. In the case of one of the latter individuals a
complete reaction in dilution of 1 in 160 was obtained both with the stock culture
and with one of the races isolated by us. An enquiry into the history of this
person elicited the information that one and a half months previous to our
examination of his blood he had suffered from remittent fever for at least a
fortnight. During this illness he was at home in his village and did not come
under medical observation. But he states that there were no objective symp-
toms except fever and profuse sweating.
In the remaining 50 cases no reaction was obtained in dilution of 1 in 10
with the stock M. Melitensis or with any of the strains isolated in India.
(2) All bloods sent to the Pasteur Institute of India for serum diagnosis of
typhoid fever. —During the period over which our present investigation lasted
more than 150 such bloods were examined with the emulsions of M. Melitensis
which were in daily use. Not one of these bloods gave a trace of agglutination
reaction in dilution of 1 in 20, the only dilution in which the preparations were
put up.
These two series of control experiments, amounting in all to over 200 ob-
servations with different races of M. Melitensis, support our contention that this
bacteriological test is a delicate one and that it affords an easy and absolutely
trustworthy method of diagnosis between this disease and other fevers which
clinically simulate it.