NationalLibraryOfScotland/medical-history-of-british-india huggingface dataset:
18
accompanied everywhere by an increase in dispensary admissions for what was
clinically malaria; it was also followed in every case where the subject was
enquired into by a noticeable increase in the numbers of people attending
hospital for splenic enlargement.
The greatest incidence of mortality was amongst infants and the study of mor-
tality at Amritsar demonstrates a very peculiar coincidence between the greatest
relative increase of mortality and the periods of life known to be most subject to
malarial infection.
Examination shortly after the epidemic of areas especially affected shows in
every instance a remarkable condition of almost universal infection with malaria.
In Palwal and the affected areas of Amritsar almost every child had splenic enlarge-
ment and malarial parasites in the blood. In Bhera and in the villages of the
Bhera thana the same condition prevailed.
When, as in the thanas of Bhalwal and Kot Momon in the Shahpur District, an
area but little affected by the epidemic is examined the spleen rate is low.
The same thing holds good for parts of Amritsar and Delhi that were compara-
tively little affected. Lastly, the enlargement of spleen found so universally is
accompanied by a proportionate prevalence of malaria parasites ; and these are
of the ordinary well known varieties.
Later in the report the malarial nature of the epidemic and its relation to the
ordinary malaria of the district will be even more apparent.
19
CHAPTER IV.
The Distribution of the Epidemic of 1908.
The epidemic affected to greater or less extent almost the whole of the central
and eastern Punjab. In the returns for towns a marked rise in deaths in the
months of October and November was almost universal. Almost all the districts
also show some increase in the death rates, those most seriously affected being
Gurgaon and Gujrat.
A detailed and very instructive picture of the distribution of the mortality is
that obtained by a method which I have described in a paper previously referred to.
In this I have explained how it is possible with considerable accuracy to map out
both the area affected by an epidemic and the epidemic intensity at different places.
The figures which have enabled me to do this in the present instance were
very kindly supplied to me by the Sanitary Commissioner of the Punjab. In
mapping the conditions I have employed for the epidemic rate the total deaths
in October, the epidemic in almost every case being at its highest in this month.
The average non-epidemic rate I have obtained by averaging the deaths in June
and July for five years, avoiding those years in which plague or cholera disturbed
the figures. Throughout I have employed the thanas as units.
As an example of the extraordinary increases in the death rate with which
we are dealing and to show how comparatively little slight inaccuracy would
affect the general results, the reader may refer to Chapter VII where a number
of examples are given.
The result of mapping out the epidemic of 1908 in this way is shown in Map
I.1 In preparing this map I have placed opposite the name of each thana the
epidemic figure relating to it and then drawn lines of equi-mortality through
these. The figures have been omitted in the final copy of the map for the sake of
clearness, colours only being used to express intensity.
Mapping out in this way the extreme limit of distribution of the epidemic,
its area would be very great, but limiting our attention to those places affected by a
death rate over five times the normal we get the picture shown on the accompanying
map. Two large epidemic areas are shown, one on the north involving Gujrat,
Gujranwala and Shahpur, and one in the south-east involving Gurgaon, Delhi
and parts of Rohtak Districts which were evidently the seat of great epidemic
intensity. Other smaller epidemic centres are shown, notably one over Ludhiana
and part of Jullunder ; but in comparison with the two large areas noted these
are small in area and low in intensity.
1 It will be found in a pocket at the end of the Memoir. The three shades of red indicate in order of
intensity a death rate during October of five, seven and ten times the normal respectively. The three shades
of blue indicate in order of intensity a rainfall during June to September of over ten, over twenty, and over
thirty inches respectively.
D2
20
These areas are clearly not chance effects, for they show not only a clearly
defined affected tract but exhibit a regular increase of epidemic intensity as we pass
from the periphery to the centre of the area.
Had the malaria of 1908 depended on merely local causes, the number of pools
about a village and so on, we should have expected to obtain a map covered with
confused figures indicating haphazard variations, as the intensity of the disease
rose or fell from thana to thana. There would be no reason why numbers of
severely affected thanas should form as it were a nucleus to epidemic areas or
that the intensity of the disease should show a more or less regular decline as we
pass outwards from these foci.
I am not aware that these features have ever been demonstrated in regard to
malaria ; and the map alone is sufficient to show that there was in the epidemic of
1908 some general determining influence over and above merely local conditions
which acted much as an area of low or high atmospheric pressure might have
acted, supposing this to affect the mortality.
Turning to a study of the details shown by the map we cannot fail to be struck
by the fact that a very noticeable feature, especially of the northern area, is the
occurrence of certain tongues of epidemic, and it will be clear that these tend
to be associated with certain of the larger rivers.
To the north the northern area is limited by the mountairs and in the east
it seems to have avoided Gurdaspur ; but on the west it extends in great intensity
along the Jhelum river to end somewhere in the neighbourhood of Shahpur. The
tract of land between the rivers Jhelum and Chenab is comparatively unaffected,
but in the neighbourhood of the Chenab river another great tongue of the epidemic
extends in a south-westerly direction. Again passing southwards the inter-
riverain tract is unaffected ; but we come to a third tongue lying broadly speaking
over the Ravi. This tongue is continued by two isolated patches further down
the river at Kamalia and Tolumba.
To the south of this tongue there is a broad patch of epidemic which would
appear from the map not to be associated with any river, but which is in
reality associated with a deserted riverain of the Beas, which river formerly
ran through Kasur and the Montgomery District. Two spots of epidemic
intensity are seen in connection with the Sutlej riverain, but otherwise this tract
is unaffected.
The southern area does not show in the Punjab any particular epidemic
tongues, though as a matter of fact, as we shall find later, this area is only partly
represented within the confines of the Punjab. A distinct association of an
epidemic area with a river is shown at Ellenabad and Jamal below Sirsa where
the river Ghagger ends blindly. Other spots are shown at Mailsi and Mitro, in
this case to the side of, but extending away from, the Sutlej and on the banks
21
of the Indus where this river first debouches from the hills in the north of the
Mianwali District. A tract occupying part of Ludhiana and extending up
between the Hoshiapur and Jullunder Districts, will be observed to lie across,
but not to extend along, the Sutlej valley.
But though the fringes of the epidemic show a relation to rivers, etc., the main
epidemic areas show comparatively little relation to any physical features and affect
without exception the thanas over a very wide extent of country.
The conditions in such areas are altogether extraordinary. In the northern
epidemic area throughout a tract covering a great part of Gujrat, half of Gujran-
wala and a part of the Lahore District, there is not a thana in which the death rate
for the month of October did not rise over seven times the normal rate, whilst the
death rate for the thana of Gujrat itself was eleven times greater than the normal
; a n d i f w e c a n c r e d i t t h e f i g u r e s t h e r e a r e v i l l a g e s i n t h e G u j r a t t h a n a s h o w i n g i n
some cases a mortality as much as thirty times the normal.
In the special focus at Bhera there are scarcely any villages showing a death
rate below 200 per mille, whilst the majority ranged between 200 and 400, and one
shows the extraordinary figure of 641 per mille.
If it were not for Bhera town itself, which shows an equally high mortality
rate, we should hesitate to credit these extraordinary values. Yet if there be
errors of registration, one would think they must err on the side of under-
estimating rather than overestimating the mortality.
In the southern area scarcely a thana south of Delhi had a death rate under
seven times the normal, whilst again there are areas in the centre of the epidemic
area which have been even more severely affected, the rates varying from ten to
seventeen times the normal.
In the thana of Nuh for example, where there normally are about 125 deaths
in the month, there occurred in October 1908 no less than 1,404 deaths. In the
thana of Hodal, which normally has about 100 deaths, there occurred in October
1,083 deaths. In the thana of Ferozepore, with a normal of 130 deaths per
month, there occurred 2,346 deaths.
In the case of the southern area the nucleus is almost coincident with the
Gurgaon District. The population of the Gurgaon District is nearly three-quar-
ters of a million. In October the recorded death rate per mille was 267. This
being the average of all villages in the district, it is more than probable that
many of them must have had rates much higher. As a rule the maximum
intensity reached by the mortality in 1908 was about 400 per mille. Such effects
are not seen elsewhere than within the circumscribed zone of an epidemic
nucleus.
In the case of towns if we refer to the figures we shall see that those situated
in areas of special intensity suffered most severely in the epidemic of 1908.
22
The following list of towns with the rate per mille for the last week in October
is taken from the returns published in the Punjab Gazette. Opposite to them is
placed the epidemic figure for the thana in which the town is situated:—
Town and thana rates,
proportionate.
Town rates high in proportion to
thana rates.
Town rates low in proportion to
thana rates.
HIGH.
Bhera .
.
. 18.1
493 Hansi
.
.
4.5
162 Jhagger
.
. 11.6
108
Palwal . . .
9.5
408 Bhiwani
.
.
4
110 Rewari .
.
.
6.7
32
Hodal .
.
.
9.6
500 Karnal
.
.
3.9
104 Gujranwala .
.
6.7
86
Amritsar
.
.
9.7
308 Jagadri
.
.
2.8
97 Jalalpur
.
8.6
128
Sonepat
.
7.7
238 Hoshapur .
.
4.9
100 Jhelum .
.
9
121
P. D. Khan .
. 19
207 Tanda Urmar
.
5.3
153 Gujrat .
.
11.1
151
Bhiwani
.
6
110 Kasur
.
.
3.6
140
Rohtak
.
.
7.6
108 Jhang
.
.
4.3
152
Wazirabad
.
7.6
174
Chiniot
.
8
163
Low.
Batala .
.
2.9
65
Umballa
.
3.6
39
Jullunder
.
3.3
50
Kartarpur
.
4.1
43
Ludhiana
.
5.7
67
Jagraon
.
4.5
78
Ferozepore
.
3.7
76
Sialkot
.
4.8
8 8
Hissar .
.
5.5
57
Kaital
.
3.6
70
Rawalpindi
2
5 6
Multan
.
3
87
D. G. Khan .
4
61
Epidemic distribution beyond the borders of the Punjab.
A description of the distribution of th epidemic would not be complete
without a reference to conditions beyond the borders of the Punjab.
23
Though no extension northwards of the epidemic is shown beyond the
Jhelum District there were areas in Rawalpindi and Attock which were just too
low to be included in the line representing the epidemic figure of 5. Had a
line representing three times the normal death rate been taken, considerable
areas in these districts would have been shown as affected.
The most important extension of epidemic conditions beyond the limits of the
Punjab was into the United Provinces. I have had no opportunity to study the
figures in detail relating to the epidemic distribution in these parts : but an exam-
ination of the monthly district figures given in the report of the Provincial Sanitary
Commissioner enables me to indicate the main distribution sufficiently in detail
for our purpose. The two worst affected districts appear to have been Muttra
and Agra which show for the whole district an epidemic figure in each case of about
7. These districts lie to the south-east of Gurgaon and thus the epidemic conditions
are continued in great intensity down the valley of the Jumna. The other districts
most seriously affected are Bulandshahr, Alighar and Budaon, all of which lie
grouped around the first two mentioned districts, thus forming the nucleus of a
large epidemic area. Around these again lies a belt of less seriously affected dis-
tricts, the epidemic figures of which grow less until they approach unity at a line,
roughly speaking, which passes through the centre of the Province from north to
south. East of this line most of the districts are unaffected.
The epidemic which in 1908 affected the United Provinces was therefore the
eastern half of the southern epidemic we have already studied in the Punjab.
What the extension of this area to the south in the Central India Agency or
what the conditions were in Sindh, I have no information to enable me to say.
24
CHAPTER V.
Previous Epidemics in the Punjab.
As already stated when I commenced the study of the epidemic of 1908 I was
under the impression that I had to deal with some newly introduced condition.
But on studying the records I was surprised to find that not only had there been
similar epidemics in the past, but that several of these were scarcely inferior in their
effects to the epidemic of 1908. Also when these were mapped out they showed
very strikingly the localised nature of the epidemic area and the peculiar increase of
intensity as the nucleus was approached which enables one to map out these
Punjab epidemics as one might do the varying levels of land by contour lines or
the differences of atmospheric pressure by isobars.
The first epidemic for which we have mortality figures occurred in 1869 ( vide
Chart 5). As detailed figures are not available I have not been able to map out
its distribution. The number of deaths recorded from fever in October and Nov-
ember was 116, 540; t hough at t hi s t i me r egi s t r at i on was l es s accur at e t han i t has
been in late years.
The years 1870, 1872 and 1875 show rather high fever figures, but the first great
rise in mortality occurs in 1876, the recorded deaths from fever in October and Nov-
ember in this year being 174,238.
The epidemic responsible for this rise in the mortality when mapped out is
seen to be a much less diffused area than that of 1908 and large tracts in the Punjab
are quite unaffected. The greatest intensity of the epidemic in this case is over
Sialkot, Gurdaspur and parts of Hoshiarpur and Jullunder. The tendency to follow
rivers is seen at three places (Chenab, Ravi and Sutlej), but there are no such long
tongues as in 1908. The death rate over almost the whole of Sialkot, Gurdaspur
and Hoshiarpur was over seven times the normal, whilst in the nucleus of the
epidemic there are epidemic figures as high as 20.
In 1878 there is an epidemic affecting chiefly Ludhiana, Jullunder and Hoshi-
arpur. The extreme limits of the epidemic do not extend beyond a line bisecting
the Punjab from north to south ; and the chief severity is confined to a compara-
tively small area. The main epidemic area lay in the neighbourhood of the Sutlej,
but the epidemic shewed a peculiar extension along the north of the Amritsar
District with a special focus about Batala. A slight degree of increased mortality
also formed tongues along the three rivers—the Jhelum, the Chenab and the
Ravi—much as happened in the epidemic of 1908. There was also a spot of
epidemic intensity at Bhera and some small areas in Gurgaon, Delhi and Rohtak.
The number of deaths recorded in the months of October and November in this
year was 180,356.
25
The following year, 1879, another epidemic, confined to the extreme south,
attacked the Punjab. The main effects of this epidemic were seen over Hissar and
parts of the Gurgaon District, the nucleus of the epidemic being very large, though
the effects of the epidemic as a whole were circumscribed. A spot of epidemic
intensity is seen over Ellenabad, Rania and Sirsa. The thanas Indri, Butana,
Nisang are also seen to be affected to some extent. The deaths in this year in
the months of October and November, in spite of the circumscribed area affected
and the defective registration, numbered 141,996.
In 1884 we have an epidemic area over Ludhiana and Umballa with a nucleus
characterised by very high figures, the thana of Machiwara showing 30 times the
normal death rate, whilst several thanas are 18 and 19 times the normal. There
are also three curious small isolated areas of high intensity, one in the low-lying
area of Thanda Urmar stretching northwards to Gurdaspur, one near Delhi and one
in the Sutlej riverain near Ferozepore. A peculiar tongue of epidemic lies along
the Jumna riverain in the Karnal District.
Again a spot of epidemic is to be seen at Ellenabad. The extreme limits of the
epidemic as shown by an epidemic figure of two or over do not extend as far west
as the Montgomery District.
In the years 1887 and 1889 there was a raised mortality, but I have not traced
out the epidemic distribution.
In 1890 we have an extraordinarily compact epidemic with an enormous nu-
cleus involving Sialkot, parts of Gujrat and Gujranwala, characterised by terrible
mortality rates, Wazirabacl having an epidemic figure of 28, Sialkot of 26 and
Gujrat of 24.
In this year the deaths numbered 246,487 in spite of the fact that large por-
tions of the southern and western Punjab was unaffected.
In 1892 there is again an epidemic area of enromous size, vide large map (Map
II). This year in fact is one remembered as the great fever year. But in spite
of the enormous nucleus extending over several whole districts there was in the
southern Punjab no trace of an epidemic. The death rates indeed for most of the
thanas in Gurgaon, Karnal and Rohtak were not raised above their non-
epidemic rates. The epidemic in this year extended further west than any previous
one and involved almost the whole of the Shahpur District as well as seriously
affecting Montgomery and Multan. Its effects were also felt northwards in
Rawalpindi and even in Peshawar. Several tongues are seen extending to the
south-west and there are some isolated spots of epidemic in the Sutlej riverain
and near Sirsa. The deaths in this year numbered 283,223 or only slightly less
than the number in 1908.
In 1894 there is a single epidemic area over Gurdaspur, Amritsar, Jullunder
and part of Sialkot and Hoshiapur, with a small nucleus to the north of the
26
Amritsar District and one over Jullunder. The deaths in this year numbered for
October and November 132,767.
In 1900 there was a large epidemic over Ludhiana, Umballa and Karnal.
To the north over Gurdaspur and Sialkot was another smaller epidemic area with
points of special intensity over Gurdaspur and Raya. In the Lahore District is
shown a small isolated area of high intensity which lies somewhat north of the
Sutlej (old bed of Beas). The deaths in the autumn of this year numbered 254,580
as against 307,316 in 1908. Therefore even so late as 1900 we have a condition
very similar to and a mortality not very far short of that in 1908.
The conditions in the year 1908 were therefore in no way new to the Punjab.
Even as regards gross mortality this epidemic was but slightly more severe than
the epidemic of 1892, and the areas of special intensity were neither so extensive
nor so severe as those of some previous years. What seems to have made the year
1908 so noticeable was the fact that epidemic conditions were diffused so generally
throughout the Punjab. This year was also the first in which two distinct
epidemic areas of large size have been present.
In years not so tremendously characterised by mortality we find that the
autumn fever exhibits the same tendency to localisation, but, being smaller in
degree and insignificant in area, such epidemics do not influence the general statis-
tics as do the great ones we have just described. In other years there are no epi-
demic areas.
For want of time I have attempted to trace out a few recent years only; 1906
is an example of a year with small epidemics; 1903 also shows incipient epidemic
a r e a s ; 1 9 0 4 w a s p r a c t i c a l l y f r e e f r o m a n y e p i d e m i c a n d i t i s n o t i c e a b l e t h a t t h e
deaths for October and November are not above the normal non-epidemic rate of
about 30,000 per mensem.
These facts show us that in the Punjab we have malaria normally exhibiting
itself in a very peculiar and definite way, one of the characters of which is the
formation over some part or other of the Punjab of what might almost be called
a malaria cyclone.
Later on we shall see that these effects are not due merely to the malaria
visiting now and again a population otherwise free from the disease, for, as we shall
see later, in years when the mortality is not above normal we still find that ano-
pheles are plentiful, that the prevalence of enlarged spleen is very great and that
parasites are found freely in the blood of children and others.
From the characters I have outlined this type of malarial manifestation might
well be called "fulminant" malaria, and I shall in future term areas severely
affected in this way "fulminant areas."
27
CHAPTER VI.
Conditions at Amritsar and Other Towns.
(i) Amritsar.
In the epidemic of 1908, Amritsar lost over 10,000 persons or one-sixteenth of
its population. Being an important city, a large trade centre and the religious
capital of the Sikhs this effect of the epidemic naturally aroused a great deal of
attention. That malaria had this effect upon the population of a city (and this
a very compactly built one even for the Punjab where the cities as a rule are very
compact), and the fact that during the epidemic towns seem to have suffered. even
more severely than the rural areas, made the investigation of conditions at Amrit-
sar very important.
Amritsar, the population of which in 1901 was 161,039, is situated on the
Bari Doab, about midway between the two rivers—the Beas and the Ravi. The
Doab, at this part about sixty miles wide, is low lying and heavily irrigated. The
city lies in a shallow depression such as I have referred to in the introduction
which, though unrecognisable to the unaided eye, acts as a line of drainage. The
soil is the usual fine silt but with a good many intercalated beds of sand. The
subsoil water lies everywhere very near the surface being at most at a depth of 6½
to 10 feet (June 1910 after a dry season), and in depressed areas during the rains
within 3 or 4 feet or less.
The city occupies an oval site about 1½ miles in the longest and 1¼ miles in
its shortest diameter. It is a walled city and very compact, the population number-
ing in parts over 500 to the acre. Even with this density the map will show that
all the land within the line of walls is not built over. But there exists a nucleus
of densely aggregated town with scarcely a break of any kind and characterised
by tall buildings and deep narrow alleys. A surrounding zone of smaller
houses less densely aggregated is also almost unbroken, but outside this again
there are in parts even considerable areas of waste land and gardens ( vide Map
III).
In my description of the conditions in Amritsar these different zones will
frequently be referred to and some brief description of them is necessary. The
central nucleus roughly speaking forms an oval lying to the west up against the
city wall. From east to west it is not quite ¾ of a mile and from north to south
slightly over ¾ of a mile ocross. On the west it is broken by the garden of a hos-
pital and near its centre it has a deserted garden, now a piece of waste ground, and
one other quite small patch of the same nature, otherwise this portion of the city
has no open spaces; one or two large tanks in the city we shall see are harmless,
E2