NationalLibraryOfScotland/medical-history-of-british-india huggingface dataset:
7
this type of curve being especially seen in the records of the extreme north-west
where rainfall is most scanty.
As a rule the curve is not interfered with or obscured by those of other
epidemic diseases. Sometimes its origin is hidden by a late cholera rise and some-
times its fall is merged in the commencement of the effects of plague, (vide Chart 1),
but as a rule it stands clear as a very definite and characteristic epidemic rise.
It is not a normal constituent of the death curve as in some years it is entirely
absent.
We can then divide our fever deaths into ( a) those returned along with other
causes of deaths going to form the ordinary normal mortality and (b) those which
are recorded during and which go to form the epidemic rise we have been consi-
dering. Normally in the Punjab the former class number about 30, 000 per mensem.
What proportion of these deaths returned as fever are really due to malaria
cannot at present even be guessed at. The term " fever" being only the
diagnosis of the friend of the deceased or of the village chowkidar cannot be
taken as at all necessarily indicating "malaria." In fact the term obviously
includes not only all febrile diseases but a great host of deaths returned as fever
for want of a better name.
The latter class which we can ascribe entirely to the direct or indirect effects
of some epidemic disease prevalent during the months of October and, November
may in an unhealthy year reach a total of 300,000 deaths or a figure about equal
to the total annual fever mortality under normal conditions.
Popularly the increase of sickness and death at times when this curve is high is
attributed without hesitation to malaria.
However inaccurate the diagnosis of " fever" may be there is no doubt that
excluding plague which has affected the Punjab very severely in recent years,
th e occurrence of a very healthy or a very unhealthy year as judged by total
mortality returns depends almost entirely upon the excess of deaths from
" fevers " which has gone to form the autumnal epidemic rise.
Whether any of the rises in the early parts of the year are due to malaria we
cannot yet say. But if they are it will be clear from the charts given that as
a rule these rises are insignificant in comparison with the extraordinary rise
occurring almost every year from " fevers " in the autumn.
We may content ourselves here by pointing out that in the case of the
a u t u m n a l e p i d e m i c r i s e m a l a r i a , i f i t b e m a l a r i a , i s e x h i b i t i n g i t s e f f e c t s u p o n t h e
mortality curve as an epidemic disease.
9
PART II.
AUTUMNAL EPIDEMIC (FULMINANT) MALARIA.
CHAPTER III.
The Epidemic of 1908.
The autumn of 1908 in the Punjab was characterised by an epidemic of
extraordinary severity. The effects of this epidemic were first prominently brought
before the public by a sudden disorganisation of the train service due to "fever
among the employees at the large railway centre, Lahore. With equal suddenness
it made its presence felt throughout the whole Punjab. Where the epidemic was
severely felt almost the entire population seems to have been prostrated by sick-
ness; and the mortality almost invariably rose in such places to a rate of several
hundreds per mille.
A very peculiar feature of the epidemic was that though it was severely felt
in the rural areas (the returns for the Gurgaon district for example showing
among a population of 687,199 a death rate during October of 267 per mile), it
seemed to reach its greatest intensity in certain of the towns and very severely
affected even the larger cities.
At Amritsar, a city of 160,000 inhabitants, it is stated that almost the entire
population was prostrated and the ordinary business of the city interrupted. For
many weeks labour for any purpose was unprocurable and even food vendors ceased
to carry on their trade. Thus not only was ordinary food difficult to obtain and
the prices excessive, but, owing to malaria among the cowkeeper class, milk, a
necessity for the very young and the sick, was practically unprocurable even at
the exorbitant rate of 8 to 12 annas per seer.
In the two months, October and November, during which the epidemic was at
its highest, 307,316 deaths were recorded in the Punjab. In Amritsar the mortality
for many weeks was at the rate of over 200 per mille. In Palwal mortality rose to
420 per mille and in Bhera to 493 per mille. Curiously enough in Delhi, a noto-
riously malarious town, the death rate rose only to 149 per mille. But a closer
examination of the statistics shows that parts of the city were much more
seriously affected than one would judge to be the case from the statistics for the
whole city; in Ward I, for instance, the mortality rose to over 300 per mille.
In the rural returns the mortality rates were not as a rule so high as those given
for badly affected towns. This might be taken as showing that the mortality was
greater in towns than in rural areas, but a study of returns from individual thanas
and villages modifies this conclusion, many villages and even whole thanas showing
mortality rates during October and November of 300—400 or even 500 per mille c
10
When I first commenced the study of this epidemic I was under the impression
that the conditions during this year were quite exceptional. This belief I am
inclined to think was general. The severity of the epidemic led many to doubt its
malarial nature and even when the probability of its being malaria was allowed
the admission was generally held to signify that some special peculiarity was to
be expected in the type of malaria present or in the mosquito which transmitted it.
In the course of my investigation it will I think be clear why I no longer look
upon the outbreak of 1908 as unique or as likely to be due to causes new to the
Punjab.
(i) Sickness.
At Amritsar an examination of the out-patient returns at the hospital showed
an increase in total admissions in September from an average of about 400 to 800
and 900 per week. The cause of this increase is entirely due to the extra number
of cases entered under malarial fevers, which rose from a number never exceeding
one hundred per week to 566 in the 3rd week in October.
In the months of February to April there is an increase noted in the numbers
of cases attending for disease of the spleen (enlarged spleen).
The city dispensary returns for the years 1900 to 1908 are as follows :—
Admissions for Malarial Fever and Enlarged Spleen at the Amritsar City Dispensary.
1900
1901
1902
1903
1904
1905
1906
1907
1908
January
.
.
71
214
143
87
289
81
82
104
96
February
.
.
71
123
111
103
203
65
41
77
78
March .
.
.
143
177
141
113
188
129
81
108
115
April .
.
.
121
182
161
194
238
147
206
147
123
May
.
.
.
128
221
191
133
240
197
129
146
124
June
.
.
.
98
222
141
128
210
176
139
178
134
July
.
.
.
99
249
163
121
200
156
116
123
139
August .
.
.
127
319
218
94
186
292
119
182
255
September .
.
486
758
246
309
309
262
200
248
2,309
October
.
.
1,032
1,336
266
1,311
306
218
395
243
3,668
November
.
.
903
560
167
1,465
199
197
397
206
1,534
December
.
.
515
298
997
569
173
131
227
150
809
TOTAL . 3,794
4,670
2,060
4,628
2,768
2,055
2,141
1,927
9,396
11
At Bhera dispensary the weekly admissions for malarial fevers rose from a
number never exceeding 50 to over 500 ( vide Chart 2). Towards the end of the
epidemic most of the excess in admissions was due to cases attending for enlarge-
ment of the spleen. At Miani the number of admissions for malaria rose from
under 50 per week to nearly 700 per week.
The nature of the mortality curves for different areas will be apparent from
Chart 3. 1 They show a sharp rise usually towards the end of September, a high
level maintained throughout October and part or the whole of November and
rates falling rapidly in December and January to normal. The resemblance of
the curve to that of the autumn epidemics previously referred to will be apparent.
It is remarkable that with the exception of the extreme south-east, where the
characteristic rise from mortality took place about a fortnight earlier than in
the northern part of the Punjab, places even hundreds of miles apart were
affected simultaneously.
A comparison of the mortality curve with the dispensary records shows that
the two curves follow one another very closely. In the case of Amritsar the
admissions first began to be affected towards the end of August, but were not
seriously increased until the second week in September; the deaths were first
markedly increased in the fourth week in September. In the case of admissions
for sickness the numbers rose to its maximum in the week ending the 3rd
October and then declined rather rapidly. The death rate was highest in the week
ending 17th October. But the numbers of deaths continued comparatively much
higher than the admissions for sickness and did not decline until the end of
November, or about a month later than the fall in sickness rates.
At Bhera the first indication of an increase of sickness occurred in the fourth
week in August; the first indication of an increase of mortality was in the middle of
September. The admissions were highest in the first week of October and mortal
ity in the third week.
At Miani sickness and mortality appeared almost coincidently, but the
admissions rose to their highest point in the last week of September, whilst the
greatest mortality was in the second week in October.
In the case of Bhera a second rise in the number of admissions occurred in-
dependently of in creased mortality reaching its maximum at the end of November.
In this town therefore the sickness outlasted the mortality ( vide next section).
Roughly speaking the increase of mortality followed the increase in sickness
by about a fortnight.
1
I t w i l l b e f o u n d i n a p o c k e t a t t h e e n d o f t h e M e m o i r .
12
Age composition of mortality.
At Amritsar deaths are recorded by the return to a Registrar of the permits
given to persons burying relations in the cemeteries. The system, so far as I have
been able to judge, is conscientiously carried out; and the fact that the city is so
densely populated makes it improbable that many burials take place except in
the cemeteries. During the epidemic over 10,000 deaths were recorded of which
we may calculate more than 7,000 must have been directly due to the epidemic.
With such an opportunity it seemed desirable to make a study of the age inci-
dence and distribution of these deaths. Particulars regarding each death were
recorded upon a slip and the results of various sortings noted. Results which
refer more especially to the distribution of the mortality in different parts of the
city will be referred to later when the conditions at Amritsar are discussed. For
the present I shall confine myself to the more general features of the epidemic
mortality as shown in the analysis of 10,202 deaths in vestigated.
Separating the total deaths under their respective recorded ages the general
nature of the mortality is evident.
Stillbirths
.
.
. . . . .
568
Children under one year .
.
.
.
.
1,389
4,528
Children over one year and under two
1,253
"
" two years " "
three .
.
958
"
" three " " "
four
.
.
576
"
" four "
" "
five
.
.
352
"
" five " "
"
ten
.
.
795
"
" ten " "
"
fifteen .
.
310
Persons aged 15 to 20
. . . . .
225
"
" 20 " 30
. . . . .
518
"
" 30 " 40
. . . . .
403
"
" 40 " 50
. . . . .
502
"
"
50 " 60
. . . . .
605
Persons over 60
.
.
.
.
.
.
1,748
Of the 10,202 deaths at Amritsar during the epidemic 5,273 deaths were there-
ore in children under 5 years of age, as against 4,929 for all other ages; 1,748 or
another 17 per cent. were in persons 60 years and over.
The plotting out of these figures gives the curve shown in Chart 4. Taking
into consideration the fact that the recording of ages must be open to many falla-
cies the regular nature of the curve is very remarkable and suggests that registra-
tion of ages is more accurate than one has suspected. The age composition of the
Amritsar population being given in the Census the actuals recorded above were
educed to rates per mille for each age, the curve made by these figures being
shown by the dotted line on the chart. The epidemic mortality though greater in
degree therefore shows the same general incidence as does the normal mortality.
13
In so severe an epidemic mortality it is surprising to find so few distinctive
features one can ascribe to the disease, the ratios suggesting only a great exaggera-
tion of normal stress.
But though at first sight the curve of deaths at Amritsar seems merely an
exaggeration of the normal, it will be seen, comparing the epidemic with the normal
figures taken from the Census of 1901, that the increase is not really proportionate
at all ages. The deaths among children under 1 year for example in the epidemic
increased only from the normal 206 to 412, whereas at the age of 5 the increase
was from 41 to 356 and at the age of from 5 to 10 years from 13 to 65.
Working out the different increases in the form of a percentage increase
curve, it is seen that there is a greater relative increase at two years of ago than at
any other time and that this effect lasts to about the age of 10.
The best demonstration of the differences between the two curves is given by
representing in terms of the standard deviations for each series the increase or
decrease of the abnormal over the normal mortality at the different ages ( vide
Chart 4).
Or the effect is very remarkably brought out by simply dividing the number of
deaths at any age which normally occur into the number recorded during the epi-
demic (vide also Chart 2). In each case the sudden drop in the curve which occurs
at about the age of 10 is very noticeable.
At Palwal 680 out of 1,057 deaths were in children under 10, and 304 of these
deaths were in infants one year of age and under. Analysis of the curve showed the
same relative increase of effect upon childhood as against infancy as noted above.
At Bhera 537 out of 703 deaths were in children under 10, and deaths in
infants one year of age and under numbered 260. In 1,014 deaths among villages
around Bhera, 832 were in children under 10 and 373 in infants one year and under.
As a matter of interest at Bhera and some other affected places the recorded
deaths for the first year of life were divided into months; the result is very
remarkable.
MONTH.
0
1
2
3
4
5
6
7
8
9 10 11
Bhera villages . 49 22 43 38 25 23 31 13 16 15 27 11
Bhera town . . 29 17 19 11 20 18 16 15 17 11 13
5
Amritsar malarious
portions . . 72
6 64 57 39 26 45 20 31 28 20 19
Amritsar Central
portions . . 54 16 32
9 13 13 14
7 15 10
8
8
Amritsar central
non-epidemic por-
tions
. . 26
6
6
4
2
3
6
1
6
7
4
5
14
It will thus be seen that the epidemic mortality has very definite characters.
Following the weekly deaths at Amritsar for each age separately the curve for
children under two years was found to rise almost sheer reaching its maximum in
the second and third week of October, but at once falling rapidly. The curve of
children under 10 rises more slowly and reaches its maximum in the first week in
November. The curve of adult deaths rises still more gradually and reaches its
maximum only in the last week in November. The curve of old people resembles
that of children under 10.
Looking at the curve shown by deaths in Amritsar it will be clear that its con-
formation is largely due to the facts we have described. The first rush upwards of
the line and the first peak is largely due to the sudden mortality amongst infants and
young children, the second peak is due to the increasing deaths amongst adults
together with the continuance of high death rate among children under 10.
Between the two peaks is a notch which is always shown in the figures for different
parts of Amritsar city. A similar notch is seen in the curves for Delhi and
Palwal.
At Bhera and Miani where adult mortality was low the second peak or hump
is not apparent, nor is the same breadth of the curve visible. Both characters are
seen, however, in the curves for Sonepat, Mehrauli and Jhelum. At Palwal the
second peak due, as at Amritsar to deaths among adults reaching their maximum
l a t e r t h a n d i d t h o s e a mo n g i n f a n t s , i s e v e n h i g h e r t h a n t h e f i r s t .
Stillbirths.
Associated with the increased mortality at Amritsar was an extraordinary
increase in deaths returned as "stillborn." The increase was so great, reaching,
in the four months September to December, the figure of 568, that it must be con-
sidered part of the effect of the epidemic. Since the records come from the ceme-
teries the term stillbirth could scarcely have been applied to any condition other
than a birth within the last three months of pregnancy or to children dying within
the first day or so of birth. We may (in order to see the significance of the figures
and allowing a latitude greater than we have indicated) consider that deaths
recorded as stillbirths represent deaths in the fœtus during the last six months of
uterine life. In this case the number for a year would be 1,136 or nearly as high
a rate as occurred amongst children after birth. If stillbirths were taken as
representing the mortality among fœtuses three months or less prior to birth, the
rate would almost continue the curve of mortality into the prenatal condition.
The distribution of stillbirths also does not follow that of the adult mortality,
but reaches its greatest height at the same period as deaths among children under
two years.
15
At Bhera and other places stillbirths were not recorded in such numbers, but
it is quite possible the conditions were not so favourable as at Amritsar for the
record of such occurrences.
(iii) Spleen Rate.
In Chapters VI to VII will be considered in detail the conditions at those
places actually visited ; but a summary of the observations upon splenic enlarge-
ment and parasite rate seems desirable whilst discussing the general characters of
the epidemic.
In order to give more information than is given by merely quoting the total
percentage of children with enlarged spleens I have adopted for the record of spleen
rate five classes, namely, (1) very large spleens reaching to the umbilicus or beyond ;
(2) spleens four fingers' or a hand's breadth below the costal margin or approx-
imately 7-10 cm. ; (3) spleens two or three fingers' breadth below the costal mar-
gin or approximately 2-7 cm. ; (4) spleens only palpable or a finger's breadth below
the costal margin (2 cm.) ; (5) spleens not palpable. In this paper are given the
percentages of these five classes always in the same order, namely, from left to right,
class I, II, III, IV, V. Following these is given the total percentage of children
with enlarged spleens, and last of all the numbers of children examined.
Immediately after the epidemic (February to April) the spleen rate in per-
centages of those places visited was as follows :—
Class
I.
Class
II.
Class
III.
Class
IV.
Class
V.
Total.
No. of
child -
ren.
Amritsar town
.
.
.
.
1.6
7.7
31.5
24.5
34.6
63.4% 1,253
Amritsar villages .
.
.
.
4
10
43
29
13
87 %
122
Palwal town .
.
.
.
.
4
15
49
19
12
88 %
147
Palwal villages
.
.
.
.
3
16
50
20
18
82 %
133
Delhi .
.
.
.
.
.
2
8
30
22
38
62 %
279
The splenic rate observed in different areas of Amritsar and the mortality
rates recorded in the areas during the epidemic are as noted below :—
Popula-
lation.
Rate
per mille
Oct. and Nov.
Division 9 .
.
. 17,206
448
3 12 40 24 19 81% 418
Division 4
.
.
.
5,460
117
0 0
4 10 86 14% 112
Division 6
.
.
.
8,335
80
Division 8 .
.
. 13,553
328
0
1 28 12 58 42% 178
Divisions 5 and 7 .
. 42,048
375
1 11 42 29 16 84% 256
16
At Delhi a sub-division of the figures into those relating to the badly affected
Wards 4, 5, and 11 lying towards the river Jumna and those relating to the com-
paratively slightly affected wards on the west of th e city gives :—
Wards 4, 5, 11
.
.
.
.
.
4 18 41 16 19 81% 114
Wards 6, 7, 9
.
.
.
.
.
5
2 29 19 49 51% 165
Later in the year (July) the following places were visited, the spleen rate being
as below :—
Bhera town .
.
.
.
.
.
1 13 47 23 16 84% 113
Bhera villages
.
.
.
.
.
2 12 51 24 10 90% 227
Miani .
.
.
.
.
.
.
5 18 35 19 21 79% 56
Gujrat town
.
.
.
.
.
2
2 17 22 57 43% 57
Gujrat villages
.
.
.
.
.
0
0 15 20 65 35% 73
(Slightly affected.)
Gujrat villages
.
.
.
.
.
1 17 35 14 32 68% 69
(Severely affected.)
All the above areas were badly affected by the epidemic. Bhera town and
tract were both profoundly affected ; Miani only slightly less so. Gujrat town
showed a mortality reaching a maximum of 247 per mille. In the case of the Gujrat
villages some were profoundly affected by the epidemic, in others the mortality
was not so great. It will be seen that the spleen rate is highest in the former.
In the Shahpur District there were areas in which, judging from the mortality,
the epidemic had been very mild or had even in some cases not effected the death
rate (Kot Momon). The following are the spleen rates in the district :—
Badly affected
.
Wegowal
.
.
1 11 23 19 45 55% 69
Dharema
Kandan
Moderately affected
Akelgahr
.
.
0 4 32 18 46 54% 98
Shahpur
Nathowal
Unaffected or very
slightly affected.
Bhalwal and Kot
Momon villages.
0
1 10 13 74 26% 67
The spleen rate therefore shows a very distinct relation to the mortality.
Parasite rate.
At Amritsar immediately after the epidemic (February) the relation of para-
sites to spleen rate was as follows :—
Spleen rate. Parasite rate.
Lakar Mandi
.
.
.
. .
.
Mahan Singh
.
.
.
.
.
.
90
66
Subanian
.
.
.
.
.
.
.
66
58
Chauk Pasian 1
.
.
.
.
.
13
20
Chauk Pasian 2
.
.
.
.
.
.
37
34
Hati Gate
.
.
.
.
.
.
.
47
50
Kanyan 1
.
.
.
.
.
. .
37
43
Kanyan 2
.
.
.
.
.
.
.
54
50
Hakima
.
.
.
.
.
.
.
93
72
17
At other places examined at this time the relations were as below:—
Spleen rate.
Parasite rate.
Atari
.
.
.
. .
. .
.
80
35
Palwal
.
.
.
.
. .
.
.
88
83
Dhatir
. .
.
.
.
. .
.
7 5
30
There is thus every reason to believe that the enlargement of the spleen noted
is in the main the effect of malaria. In Delhi a number of very large spleens were
punctured during life and at Amritsar spleen smears were obtained from the
cadaver ; but in none were the parasites of Kala Azar found. Major James, I.M.S.,
has similarly failed to find in the Punjab evidence of Kala Azar. This disease is
scarcely likely therefore to interfere seriously with the use of the spleen test for
malaria.
The types of parasite found at the different places visited were as follows:—
Simple
tertian.
Malignant
tertian.
Quartan .
Amritsar
.
.
.
.
.
.
.
.
.
. Present.
Present.
Present.
Delhi .
.
.
.
.
.
.
.
.
.
.
„ „
„
Palwal .
.
.
.
.
.
.
.
.
.
.
„
„ 0
Dhatir .
.
.
.
.
.
.
.
.
.
.
„
„ 0
Atari .
.
.
.
.
.
.
.
.
.
.
„
„
0
Gujrat .
.
.
.
.
.
.
.
.
.
.
„
„ 0
Dhera .
.
.
.
.
.
.
.
.
.
.
„
0
0
Shahpur
.
.
.
.
.
.
.
.
.
.
„
0
0
There was therefore so far as one could see no new form of parasite concerned.
Without seeing the conditions during the epidemic it would be rash to say whether
one or the other of the known forms of the parasite were especially concerned or not.
But the fact that almost immediately after the epidemic all three forms, and
especially the two commoner species, tropical and simple tertian, were found in
the blood of the children at Amritsar does not suggest any one parasite being
specially concerned.
(iv) Nature of the Epidemic.
We have already given sufficient evidence to remove any doubt as to the true
nature of the epidemic.
It exhibited the well known incidence of the ordinary autumnal fever of the
Punjab corresponding with the prevalence of malarial parasites, as shown by the
observations of Dr. Stephens, Major James and myself, among the natives of Mian
Mir, and by ourselves and others in European soldiers in cantonments. It was
D