NationalLibraryOfScotland/medical-history-of-british-india huggingface dataset:
28
since they do not breed anopheles and are surrounded by the least malarious parts
of the town. The main roads are lined with shops and off these open narrow
"gullies" which correspond to the slums of European towns, and are often so narrow
that two people cannot easily pass one another without stepping aside. In parts
there are buildings 4 or 5 stories high massed together, so that the gullies between
them are quite dark and gloomy. For the purpose of description this portion of
the town will be called the central area.
Along its western side are the densely crowded quarters known as Katras
Moti Ram, Lohgohr, Dulu and Chitta Katra. A small portion near the Hospital
garden already referred to known as Sant Singh is occupied by sweepers and
cowkeepers, and is perhaps more correctly considered a portion of the outer zone.
Towards the centre are the crowded Katras Chauk Pasian, and Chowrasta Atara,
Churt Singh and Hari Singh. To the east lying in Division 6 are the grain and
salt markets. To the south is Killabangian, partly a comparatively well-to-do
quarter and partly occupied by cowkeeper class, this latter portion forming as it were
a small bay in which the outer zone penetrates further into the centre of Amritsar
than usual. A similar bay occurs on the south-east corner (Bhai Busti Ram),
and a small island (K. Khai) of high houses occupied by well-to-do Hindus lies to
the south of the central area in the Khazana Division ( vide Map III). These
points are all of importance in regard to observations later on upon the mortality
and spleen rate.
As one approaches the periphery the tall many storied buildings of the central
area give place rather abruptly to buildings one or at most two stories high, usually
built of brick with flat mud, roofs. So soon as this outer zone is reached, open yards,
stables and such like conditions are found, and cowsheds which scarcely exist in
the central area are here numerous. The Division known as Kunyan is almost
composed of the houses of cowkeepers, whilst large communities of the same class
live in Mahan Singh and elsewhere.
As one approaches the walls open spaces are found encroaching upon the city
or what evidently have been gardens, now exist as waste land and lie between
crowded collections of mud and brick houses. To the south and west the lands
are for the most part cultivated or waste, but to the north-east in Jalewalyan
many are still kept up as private gardens. In Division 2 what would elsewhere
be land of this kind has been made into a Municipal garden.
Though forming what might seem to be the least important portion of the
city, this peripheral zone is densely populated and taken collectively its inhabitants
equal or exceed the apparently more important central zone. Thus Division 9,
which consists wholly of houses such as we have described as forming the outer
zone, has a population of 17,206. Division 7, also wholly composed of this class
of house, has a population of 12,272, and Division 5 of 10,521.
29
As far as the arrangement of the Municipal Divisions will allow us we may make
the following rough calculation of the number of persons living in the central and
peripheral zones respectively :—
PERIPHERAL.
CENTRAL.
Division 9
. .
.
.
17,206
Division 4
.
.
.
5,460
Division 7
. .
.
. 12,272
Division 6
.
.
.
8,335
Division 5
. .
.
. 10,521
Division 8
.
.
.
13,553
Division 3
. .
.
.
6 , 6 3 9 Division 10
.
.
.
18,001
Division 2
. .
.
.
12,616
Division 11
.
.
.
16,748
Division 1
.
.
.
.
15,796
Division 12
.
.
.
15,081
TOTAL
.
75,050
TOTAL
.
77,178
In Jalewalyan and Chowni Nehangen there exist isolated blocks of houses,
which might almost be considered as hamlets, being surrounded as they are on all
sides by waste ground, gardens, etc., and the conditions in those areas resemble
closely those found in villages. The same applies to houses on the extreme out-
skirts of the city to the south.
The peripheral zone for the most part, however, forms an unbroken extent of
city differing from the central zone, chiefly in the fact that the houses are low, that
there are many stables and cowsheds and in some parts small or larger compounds.
Roughly speaking this zone is about a quarter of a mile wide surrounding the
central area on the north, east and south. It comprises four great quarters,
Khazana, Gurba Singh, Ramgurian and Mahan Singh, lying roughly to the south-
west, south-east, east and north-east, respectively. The first in reality comprises
Katras Khazana, Hakiman, Karam Singh, the second Gurba Singh and Ghumarian
and the latter Baghian and Mahan Singh, but for our purpose the former names
will suffice. The areas spoken of will be seen on the map.
Khazana contains a large proportion of country people and potters ; it also
is a centre of Mahomedan and Kashmiri weavers who carry on their trade to a
large extent under petty employers. Gurba Singh is an extraordinarily densely
inhabited area occupied by a squalid population of potters, cowkeepers and culti-
vators. Ramgurian is chiefly remarkable as being largely populated by those
who go into the central zone to work under shopkeepers or in the manifold trades
carried on in Amritsar. There are also large communities of middle and low class
Sikhs who carry on such work as carpentering and a considerable number of
Kashmiris. Mahan Singh is a crowded quarter largely occupied by cowkeepers
and Kashmiris.
The immediate surroundings of Amritsar appear at first sight as a maze of
waste land, excavated tracts and large pools of water, the general features being
shown in the accompanying map (Map III). Considered more carefully it can be
30
made out that between the city and the original surface of the land, for the most
part cultivated and bearing crops or lying fallow as the case may be, is an excavated
zone in some places a mile in width, from which more or less recently or remotely
millions of tons of soil have been excavated. In part these excavated lands are
dry, in part covered with water. To the north-east of the city the subsoil level is
very high and the appearance is that of a sodden marsh, the land when not covered
by water showing saline efflorescence and a stunted unhealthy looking growth
of grass.
Around the city lies a drain evidently intended to cut off to some extent the
flow of subsoil water from the north-east. This drain in its upper parts is full to
the brim of sluggish water covered with lemna but flows more swiftly as it passes
to the south. Nearer the city is a second drain full of rank vegetation and heavily
polluted. It rarely contains larvæ.
When the pools and sheets of water are examined more closely many of them
are seen to be so foul with sewage that as regards mosquito larvæ they are quite
sterile. Others less polluted and of a vivid green from the growth of blue
green algæ serve as breeding places of chironomus, but are quite unsuitable
for "anopheles" or even "culex."
Previous Epidemics at Amritsar.
The present epidemic is not the first from which the city of Amritsar has
suffered, nor even the most severe. The recorded deaths in October 1881 numbered
5,582 or about 1,500 more than they did in October 1908. Epidemic conditions
in the Punjab generally were not very severe in this year and even in Amritsar
District the mortality bore no relation to that in the city. It seems very probable
that the severity of the outbreak was associated with economic conditions affecting
the large bodies of Kashmiri workers who about this time were adversely affected
by the decay of the shawl trade in Amritsar.
Other epidemic years have been 1876 when deaths in October numbered
2,430, 1878 when there were 1,690 deaths, and the years 1890 and 1892 when,
however, deaths in October only numbered 1,254 and 1,663, respectively.
An epidemic, with 10,000 to 12,000 deaths, is also recorded as having occurred
in 1867.
Distribution of Epidemic Mortality in Amritsar.
In Chapter III the result of an analysis of the Amritsar deaths has been given
according to ages and other general conditions. But the material was also made
use of to ascertain the distributions of mortality in the city.
For this purpose Amritsar was divided into 44 areas which represented very
roughly about the same population and, so far as could be seen, were homogeneous
within themselves.
31
The slips upon which the locality of the death were recorded were then
sorted. so as to obtain information regarding the deaths in each of the chosen
areas. In noting the final results certain of these areas were massed together, but
only such as were found to exhibit no essential differences in regard to mortality.
Unfortunately the only areas in Amritsar for which the population is known
(the divisions) lie for the most part radially, so that they include portions of both
ceatre and periphery of the town. Three divisions, however, 4, 6 and 8, are wholly
central and six divisions, 1, 2, 3, 5, 6, 7 and 9, are mainly peripheral ( vide Map
III). For the sake of getting rates per mille I have given the figures as they work
out for these wards in the different months of the epidemic. For the sake of
comparison the mortality of divisions 10, 11, and 12, which lie along the western
portion of the town and compose the western half of the central zone, are also given.
August.
September.
October.
November.
December.
Division 1 .
.
.
.
.
37
73
311
235
96
Division 2 .
.
.
.
.
40
99
289
204
108
Division 3 .
.
.
.
.
52
166
231
142
90
Division 5 .
.
.
.
.
67
141
438
277
144
Division 7 .
.
.
.
.
81
162
494
289
151
Division 9 .
.
.
.
.
70
113
464
434
202
Division 4 .
.
.
.
.
15
42
119
116
55
Division 6 .
.
.
.
.
9
12
86
75
62
Division 8 .
.
.
.
.
71
8 0
343
315
145
Division 10 .
.
.
.
.
37
51
293
192
115
Division 11 .
.
.
.
.
5 4
8 0
342
250
150
Division 12 .
.
.
.
.
76
78
360
290
170
These figures show distinctly that the central parts of the town were less affected
than the periphery. But they show also that even the centre was subjected to
epidemic conditions. The extent to which the densely populated quarters, Dulu,
Lohgarh and so on, which make up Divisions 10 and 11, also suffered is well
demonstrated.
For a more detailed survey it has been necessary to employ the methods of
using epidemic figures.
Mapped out according to epidemic figures not only is the general distribution
of mortality shown, but by using the figures for the different months, August to
December, the history of the invasion of the epidemic can be very clearly traced
32
The results shown are worth some detailed consideration.
In August a raised death rate was already apparent throughout most of the
outer portion of peripheral zone ( vide Map 6). A rate equal to double the normal
was also seen in Killabangian cowkeeper quarters already referred to as penetrat-
ing like a bay into the southern portion of the central area. In Dulu and the
crowded quarters to the west the death rate was not yet raised. The highest
epidemic figures are 4 in the squalid and densely crowded Ghumarian quarter and
2.8 in the hamlet zone at Jalewalyan.
In September raised mortality had mapped out by default with great precision
the boundaries of the central zone, the only part of this zone affected being the cow-
keeper quarters in Killabangian and the strangers quarters near the Golden Temple.
The whole peripheral zone, however, showed epidemic figures of 2 or over. At this
time the extreme outer portions in several instances (Hakiman, Gurba Singh and
Mahan Singh) had figures of over 3, and the figures for the two areas, Ghumarian
and Jalewalyan, reached 6.5 and 8.8, respectively. The areas Sant Singh and
Lohgahr on the west show an epidemic figure of 2, but in Dulu and other parts of
the city on this side the death rate is still low.
By October a most remarkable invasion of the whole city has taken place
; D u l u a n d q u a r t e r s t o t h e w e s t h a v e b e c o m e v e r y b a d l y a f f e c t e d s h o w i n g e p i d e m i c
figures of 7.3 to 7.5. Katras Kanhayan, Jamal Singh, the inner portions of Ram-
gurian and most of Killabangian similarly exhibit a mortality of from 6 to 8 times
the normal.
The extreme central area, though comparatively less affected, shows figures
representing a death rate of from 3 to 4 times the normal.
The condition in November is much the same, but there has been an extension
of high mortality into Karam Singh.
In December the mortality has fallen everywhere, though comparatively more
in the outer zone than in the centre, so that with a few exceptions the whole city
shows uniformly an epidemic figure of 3 or 4. Khazana, Ghumarian and Dulu still
show comparatively high rates.
The rapidity with which the invasion at the beginning of October took place
is very remarkable and is well shown in the following table which gives the week in
which the first sign of serious increase of death rate and that at which the
maximum rate was attained:—
First marked increase.
Maximum.
Gurba Singh
2nd week September .
. 2nd week October.
Ghumarian
2nd" ". 1st " "
Mahan Singh
2nd " "
33
First marked increase.
Maximum.
Khazana .
.
.
. 3rd week September .
. 3rd week October.
Jalewalyan .
.
.
. 3rd„ „
.
. 3rd „ „
Ramgurian .
.
.
. 3rd „ „
.
. 1st „ „
(Outer portion.)
Bagian
.
.
. . 4th „ „
.
. 2nd „ „
Sher Singh .
.
. . 4th „ „
.
. 2nd „ „
Lohgahr .
.
. . 1st „ October
.
. 4th „ „
Jamal Singh
.
. . 1st „ „
.
. 1st „ November.
Kanyahan .
.
.
. 1st „ „
.
. 3rd „ October.
Ramgurian .
.
.
. 1st „ „
.
. 3rd „ „
(Inner portion.)
Bagh Singh .
. .
. 2nd „ „
.
. 3rd „ „
Dulu
.
. .
2nd „ „
.
. 3rd „ „
Beli Ram .
.
.
. 2nd „ „
.
. 3rd „ „
Nimuk Mandi .
.
. 2nd ” „
.
. 3rd „ „
Chittra Katra .
.
. 2nd „ „
.
. 3rd „ „
Sant Singh .
. .
. 2nd „ „
.
. 3rd „ „
Mohram .
.
. . 3rd „ „
. . 4th „ „
Killabangian
.
.
. 3rd „ „
. . 1st „ November.
Chauk Pasian .
.
. 3rd „ „
.
. 2nd „ „
The salient features shown by this study of the mortality are :
—
(1) The appearance of an outer ring of increased mortality in August, the
extension of this in September to all parts of the city except the central zone and
the almost simultaneous appearance in October of intense epidemic conditions in
every part of the city except certain areas in the extreme centre.
(2) The prevalence of special intense epidemic conditions in certain parts,.
notably Khazana, Ghumarian and Mahan Singh.
(3) The existence of a central area which was comparatively speaking
protected from the effects of the epidemic.
The distribution of enlarged Spleen and Parasites immediately following the
Epidemic of 1908.
In February 1909 I commenced at once a spleen survey of the city. Observa-
tions taken at 142 places in the city enabled the distribution to be mapped out fairly
accurately.
The accompanying map of Amritsar shows isosplenic lines drawn in accord-
ance with these observations. When particular interest attached to any set of
observations all the children that could be obtained were examined and the ground
gone over several times. This has enabled one to place considerable reliance on the
course of the isosplenic lines ; but unfortunately in one or two instances in the very
place where reliable rates would have been interesting the number of children that
F
34
could be obtained was very small. The results were recorded under the system
described in Chapter III.
The map shows in the first place that around Amritsar there is a broad zone
within which the spleen rate is never below about 75%.
Commencing at the north-east corner of the city we find this zone including
the greater part of Division 1, all the outer portion of Division 2 and the whole of
Division 3. Passing down the eastern side of the city it included most of Division 5
and practically the whole of Divisions 7 and 9. Along the western border of the
city it becomes narrowed down and disappears opposite Lohgahr and the crowded
Division 11. About half of the total area of the city is thus included in this zone.
Within the 75% zone lies another zone in which the spleen rate is lower. Tak-
ing a limit of 75 to 50% this zone extends inwards on the north as far as the north-
ern limit of Division 11. In a broad band it follows roughly the outer edge of the
central area until it reaches its eastern border. Here it narrows very remarkably,
there being in this neighbourhood an extraordinarily abrupt transition from the high
spleen rate of the outer zone to a very low spleen rate. ( Vide Map III.)
Following the zone southwards it broadens again and sweeps round the south-
eastern corner of the central area passing through Killabangian, broadens out over
Chitta Katra and Dulu, is evident in Divisions 11 and 12 and so completes
the circuit of the town.
Inside this zone which practically girdles the central area the spleen rate very
rapidly becomes reduced and though one can make out imperfectly a zone of spleen
rates between 50 and 20% this is narrow and difficult to follow. It is broadest
however where the zone 50 to 75% is broadest and narrow where this zone is
narrow.
The portion of town within the 20% spleen rate line roughly includes only the
extreme centre of the city and does not measure more than a quarter of a mile
across. In portions of this the spleen rate has been 0, in others as high as 17%.
All the zones mentioned follow fairly closely the same trend, that is they all
widen or narrow at the same point, but there are exceptions which will be
referred to.
Along the north of the town the bands are broad and uninterrupted and follow
almost exactly the boundaries of the central area. But at the north-east corner
there is a disturbance in the line caused by a block of comparatively high buildings
projecting outwards. This encroaches on the 75% zone, but does not affect the 75
to 50% zone.
Having passed round this obstruction and another group of high buildings
there is a distinct bay formed in which the spleen intensity penetrates more deeply
than usual.
35
The conditions at this point will be referred to later. Vide conditions at
"Allowalian."
After passing in a convex curve immediately behind the Golden Temple and
its surrounding buildings and gardens the zones again pass inwards to form a deep
bay, corresponding to an extension of low houses into the central zone. The ex-
tension however of high spleen rates and mortality during the epidemic was greater
than this would seem to account for. ( Vide conditions at K. Jamuan.)
Again passing round the south end of the central area in a broadly convex
manner, the zones bend northwards to cover a broad tract of the city which extends
from the south-west corner inwards for a distance of over half a mile. An interest-
ing feature at this point is the occurrence of an outstanding island with spleen
contours of its own corresponding to the group of high houses about Kucha Khai
which had already been alluded to.
At this point also there is another deep bay extending into the cowkeeper area
of Killabangian in which, though situated deeply within the city, the spleen rate
was about 100
% .
The conditions in the zones as regards spleen rate differ not only in regard to
the total percentage of enlarged spleen but also as to the degree of enlargement
(vide Chapter XIV).
The rates for the different zones given in extension 1 are as follows :—
100—75 zone. Khazana
.
.
.
.
.
7 15 43 24
9 91% 163
Mahan Singh
.
.
.
.
1 14 41 33 10 90%
70
Division 7. (Gurba Singh and Ghu-
merian)
.
.
.
.
2 12 45 25 16 84% 158
Chittra Katra
.
.
.
.
12 42 31 15 85%
55
Cowkeeper Killabangian
.
.
10 43 31 13 87%
83
Jalewalyan and Ramgurian .
.
1 8 43 26 21 79% 131
Island (K. Khai) .
.
.
.
4 25 12 58 42%
48
TOTAL ZONE 100—75 excluding K. Khai
.
3 12 44 27 14 86% 660
75—50 zone. Sant Singh .
.
.
.
.
4 42 27 27 73%
52
Allowalian .
.
.
.
.
1 10 21 31 37 63%
74
Killabangian
.
.
.
.
6 37 16 40 60%
67
Churt Singh
.
.
.
.
2 5 26 48 52% 75
TOTAL ZONE 75—50
.
4
4 30 25 38 62% 268
V i l e
p a g e 1 5 , C h a p t e r I I I .
F 2
36
50—20 zone. Division 12
.
.
.
7 41 51 49%
41
Tunda Talab
.
.
.
.
2 13 17 67 33%
46
Chauk Pasian
.
.
.
.
2 21 76 24%
80
TOTAL ZONE 50—20
.
6
6 25 67 33% 167
Central zone .
.
.
.
. .
.
4
9 86 14%
112
From these figures it will be seen that not only do the different zones differ
from one another in regard to the percentage of enlarged spleens among the
children but that there are in the outer zone areas of special intensity shown by a
greater average size of the spleen, the most noticeable of such areas being Khazana.
It will be clear that there is a very close connection between the distribution
of enlarged spleen and the epidemic mortality.
A line representing the inner margin of the 50—75% spleen zone would mark
off almost exactly the extension of very high mortality into the city ; whilst the
parts of the city showing under 30% spleens would represent those parts that
were comparatively little affected by mortality.
Spleen rate among Adults.
The distribution of the spleen rate in adults followed the same course as did
that among children, as will be seen from the following data :—
Spleen to
umbilicus.
Other classes
of spleen.
Not pal-
pable.
Percentage
enlarged.
Number
examined.
Peripheral zone
.
.
.
.
13
33
54
46
344
Intermediate zone .
.
.
.
2
25
73
27
301
Central area .
.
.
.
.
2
12
87
13
42
Where the children showed about 100%, adults usually showed about 50%
enlarged spleen. With lower rates the percentages dropped more in proportion
among adults than among children. On the extreme periphery of the city a large
proportion of adults showed very large spleens reaching to the unbilicus or beyond.
Parasite rate.
The relation of the parasite rate to the spleen rate in Amritsar has already
been given in Chapter III. Further details ascertained by quantitative observa-
tions (the numbers of parasites in a 100 fields being noted) are recorded in the table
below. In this method the expression negative is only a comparative term meaning
that no parasites were found in 100 fields. A great advantage of the method is
37
that observational error tends to lessen as the columns pass from right to left
whilst observations of different observers are comparable. ( Vide Chapter XIV.)
Infects
over 100
per 100
fields.
Infects
over 20
per 100
fields.
Infects
over 5
per 100
fields.
Infects
under 5
per 100
fields.
Nega-
tive.
Percent-
age in-
fected.
Spleen
rate.
Khazana .
.
.
.
.
.
1
9
6
10
10
76%
93
Mahan Singh .
.
.
.
.
..
1
9
5
8 66%
90
Jamal Singh, 75—50 zone .
.
.
1
3
4
4
6
65%
66
Hati Gate, 75—50 zone .
.
.
1
3
6
1
11
50%
47
Kanyan, 75—50 zone .
.
.
.
..
2
2
1
5
50%
54
Tunda Talab, 50—20 zone .
.
.
. .
..
1
2
4
43%
37
Chauk Pasian, 50—20 zone .
.
.
..
1
6
1
15
34%
37
Chowrasta Atara, central zone .
.
..
1
..
4
14
26%
13
Considered in regard to the species of parasite found the results were as
follows:—
Simple
tertian.
Malignant
tertian rings. Crescents.
Quartan.
Khazana
.
.
.
.
.
.
.
24
2
4
2
Mahan Singh .
.
.
.
.
.
.
11
1
3
4
Jamal Singh
. .
.
.
.
.
.
11
0
2
0
Hati Gate
.
.
.
.
. .
.
11
0
0
0
Kanyan
.
.
.
.
.
.
.
5
0
1
0
Tunda Talab .
.
.
.
.
.
.
3
0
0
0
Chauk Pasian .
.
.
.
.
.
.
8
0
2
1
Chowrasta Atara .
.
.
.
.
.
5
0
1
0
TOTAL
.
78
3
13
7
Breeding places of Anopheles at Amritsar.
Breeding places outside the city. —The accompanying map (Map III) shows
the places in which anopheles have been found breeding within and around
Amritsar.