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3
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CONTENTS.
PART I.
I n t r o d u c t i o n .
P A G E .
CHAPTER I.—Physical Features, Population and Rainfall .
.
.
.
.
.
.
1—4
CHAPTER II.—Autumnal Epidemic Malaria
.
.
.
.
.
.
.
.
.
5—7
PART II.
Autumnal Epidemic (Fulminant) Malaria.
CHAPTER III.—The Epidemic of 1908
. . . . . . . . . .
9—18
CHAPTER IV.—The Distribution of the Epidemic of 1908 .
.
.
.
.
.
.
19—23
CHAPTER V.—Previous Epidemics in the Punjab
. . . . . . . .
24—26
CHAPTER VI.—Conditions at Amritsar and Other Towns .
.
.
.
.
.
.
27—51
CHAPTER VII.—Conditions in Rural Areas
.
.
.
.
.
.
.
.
.
52—62
CHAPTER VIII.—Conditions in Non-Epidemic Areas and in Epidemic Areas in Non-Epidemic
Times
.
.
.
.
.
.
.
.
.
.
.
.
63—70
CHAPTER IX.—Epidemic and Endemic Malaria
.
. . . . . . .
71—74
PART III.
Determining causes of Fulminant Malaria.
CHAPTER X.—Anopheles of the Punjab .
.
.
.
. . . . . .
7 5 —8 9
CHAPTER XI.—Rainfall and Temperature in Relation to Epidemic Malaria
.
.
.
90—97
CHAPTER XII.—Physical Features in Relation to Epidemic and Endemic Malaria
.
.
98—104
CHAPTER XIII.—The Human Factor
.
.
.
.
.
.
.
.
.
.
105—113
PART IV.
Experimental work on the Mechanism of Fulminant Malaria.
CHAPTER XIV.—The Nature of Intense Malaria
. . . . . . . . 115—117
CHAPTER XV.—Experiments upon the Quantitative Factor in the Transmission of Proteo-
soma to Sparrows by the Bites of Culex
.
.
.
.
.
.
118—125
PART V.
Summary of Conclusions
.
. . . .
127—129
PART VI.
Considerations on the Chief Methods to be advised in the Prophylaxis of Malaria in the Punjab
131—135
[ i i ]
Large Maps.
I . — 1 9 0 8 E p i d e m i c .
II.—1892 „
III.—Amritsar.
IV.—Rainfall, 1908.
V.—Rainfall, 1892.
Small Maps.
6. —Four smal l maps of Amri tsar sheavi ng mortal i ty di stri buti on.
7.—Plan of Delhi City.
8.—Amritsar and Gherinda thanas.
9.—Gujrat thana.
10.—Bhera and surrounding thanas.
11.—Epidemic frequency.
Charts.
1.—To shew autumnal epidemic rises.
2.—To show effect of epidemic on dispensary admissions.
3.—To show mortality curves for Amritsar, Pal al and Bhera.
4.—Age incidence of mortality during epidemic.
5.—Fever deaths for the years 1869—1908.
6.—Correlation of fever mortality with rainfall.
7.—,, fever, mortality, rainfall and prices.
8 . — S h e w i n g n a t u r e o f ' ' S p l e e n r a t e . "
9.—Shewing nature of " Infection among native children."
All these maps and charts will be found in a pocket at the end of the Memoir. On the large coloured
maps the three shades of red indicate in order of intensity a death rate during October of five, seven, and ten
times the normal respectively ; and the three shades of blue indicate in order of intensity a rainfall during
June to September (inclusive) of over ten, over twenty, and over thirty inches respectively.
Malaria in the. Punjab.
PART I.
INTRODUCTION.
CHAPTER I.
Physical Features, Population and Rainfall.
THE Punjab, one of the Provinces of India, along with the much smaller
North-West Frontier Province, forms the extreme North-west corner of the
Empire. Considerable areas within the political boundaries, such as Kangra, are
entirely mountainous, but the main portion of the Punjab and the portion we
are concerned with, since it is here that malaria assumes so great an importance,
is the great alluvial plain, almost equalling in area Great Britain and carrying a
population of 20,000,000, which stretches from the foot of the Himalayas until it
terminates to the south in the desert of Rajputana.
The Province proper, excluding dependent States, consists of twenty-seven.
districts with an average area of from 3,000—4,000 square miles. Those districts
situated to the West and those bordering upon the desert to the South receive but
little rainfall and are comparatively sparsely inhabited. The greatest density
of population is found in the districts lying in the submontane regions beneath
the Himalayas and especially in the three contiguous districts, Sialkot, Amritsar
and Jullunder, which together support a population of 3,025,324 with a density of
from 544 to 641 persons to the square mile.
As is usual in India the rural population greatly exceeds the urban being in
1901, 88.44 per cent. of the total. But there are three cities, Delhi, Amritsar and
Lahore, of over 100,000 inhabitants, 17 large towns of from 20,000 to 100,000
inhabitants and 151 towns with less than 20,000 inhabitants, the urban popula-
tion in 1901 amounting to 2,595,372. The total number of villages in British
territory in 1901 was 36,011, the greatest percentage of the rural population (52.7),
living in villages of from 500—2,000 inhabitants.
For the most part conditions throughout these wide areas are very similar,
villages consisting of solid mud built houses lie scattered over a plain, level as far
as the eye can see. In parts the major portion of the land is cultivated ; in others B
2
large tracts of bare soil lie untouched and liable during the rains to become sheets
of standing water. In almost every case, except where land is particularly valuable
or sandy, small towns and cities alike, since they are all built of mud or bricks made
locally, are surrounded by excavations. Where the village or town is an ancient
one the excavated material accumulates until a large mound is formed upon which
the modern village or town is built. In such cases the surrounding excavations
which have perhaps taken centuries to form are out of all proportion to the buildings
now in existence. Some idea of the size and extent to which these excavations
may reach can be gathered from the account given later of the city of Amritsar.
The soil of the Punjab is for the most part a fine silt deposited by the rivers
whose action has actually formed the land. It is peculiarly impervious to water
and is rendered more so by a tendency to the formation of a concretionary layer
of so-called "Kunker" a few feet beneath the surface. Even where the soil is more
sandy, water running over it gathers a fine mud. which when deposited forms a
highly impervious layer greatly hindering absorption, so that shallow pools often
disappear as much by evaporation as by being absorbed into the soil.
The imperviousness of the soil added to the level character of the country
results (wherever heavy rain falls) in large surface collections of water and even.
of floods temporarily submerging large tracts of country.
A curious physical feature characterising the Punjab and important in this
connection is the comparative rarity of small streams. Between the Beas and the
Ravi, a distance of about 50 miles, it is doubtful if more than one or two such minor
streams are crossed, storm water finding its way along shallow depressions only
apparent to the expert hydrologist or along artificially cut drains. At Palwal it is
necessary to carry the drainage a distance of seven miles before it can be discharged
into a nullah. At Amritsar the city drain extends to a distance of twelve miles
before it meets a nullah and their discharges not into any deep channel but more
or less on to the surface of the country.
Passing through the Punjab one might almost say that, with the exception
of the rivers, the country as a whole is featureless. It is only by experience that
one learns to realise that though apparently so flat there are, winding through the
land, great riverains lying at a slightly lower level than the surrounding country.
In the more recent of these riverains there still flow, winding in great curves from
side to side, one or other or the rivers of the Punjab. Others are now deserted
by the rivers which formed them, as in the case of an old riverain in the Montgo-
mery District and an old bed of the Beas which runs through Kasur. Still older
riverains have lost much of their distinctiveness, but remain nevertheless as
depressed areas and retain the physical features which characterise these tracts.
All such riverains are peculiarly liable to flooding. This may take place either
by rain water collecting and being unable to drain away sufficiently quickly or by
3
the overflow of the river which runs through them. Even deserted riverains
are apt to be flooded by their original rivers when the waters in these reach an
excessive height.
Another important feature of the riverains is the fact that the subsoil water is
near the surface. This is equally the case whether the riverains be narrow or wide.
In certain places the rivers have reduced very large tracts to their flood plain level,
as has happened for example in the Jhelum riverain above Shahpur where a tract
more than thirty miles long and on an average more than ten miles broad lies near
flood level. Other examples are seen where the Sutlej near Ferozepore has formed
a great loop northwards leaving a riverain behind it more than ten miles broad, and
north of Lahore city where the thana of Muridke lies in a great depressed area
crossed by old channels of the Ravi and other streams carrying the drainage from
Sialkot.
Everywhere in such areas the level of the subsoil water is high and after
heavy rain it may remain for months within three or four feet of the surface.
Between the rivers of the Punjab are strips of country known as the Doabs.
On the whole the lands of the Doabs are at a comparatively high level and they are
much less liable to floods than the riverains. But they are by no means entirely
exempt ; for the peculiar conformation of the ground lends itself to the formation
during heavy rains of extensive collections of water. The conditions as regards
subsoil water in the Doabs is stated to depend a great deal upon the amount of
irrigation to which they have been subjected. Throughout most of the Rachna
Doab between the Ravi and the Chenab and the Zech Doab between the Chenab
and the Jhelum the subsoil water is at a considerable depth (40 feet or more).
These Doabs are not only subject to a small rainfall but have only comparatively
recently been irrigated. Throughout the northern portions of the Bari Doab which
lies between the Beas and Ravi and which has been for a long time heavily
irrigated the level of the subsoil water on the contrary is high.
Over the Doabs rainfall precipitation tends to be diminished as will be seen
from the rainfall maps. There is thus a cyclical tendency for a tract like the Zech
Doab which we shall study in more detail later to have a small rainfall and a low
subsoil water, and to be comparatively free from the liability to floods.
West of the Jhelum rainfall does not reach proportions sufficient to cause
extensive flooding and such floods as occur arc usually the effects of rivers over-
flowing their banks. But in the eastern half of the Punjab it is doubtful whether
any large tract however situated can be considered free from the possibility of
flooding should an unusually heavy monsoon rain happen to fall there.
The chief rain of the Punjab is that which falls during the south-west
monsoon. This monsoon breaks as a rule in the Punjab about the middle of June
and continues for about two months. The heaviest rain falls along the eastern
B 2
4
border and on the districts lying along the foot of the Himalayan Range. Passing
westwards the fall becomes progressively less until the regions to the extreme west
even in a year of heavy monsoon receive less than 10 inches at this time.
Other showers fall during the year but the preponderating effect of the mon-
soon will be evident from the fact that nearly three-quarters of the total average
rainfall is that which falls during this period.
Before concluding our remarks on the physical features of the Punjab it will be
necessary to refer briefly to the irrigation systems. As is well known the Punjab
is the seat of enormous irrigation works which have brought thousands of square
miles of land within the power of the ryot to cultivate. If one looks at a map of the
Punjab prepared to show the distribution of the canal system we shall see how
extensively irrigation is carried on. But whilst enormous tracts are covered with a
net-work of main canals and their distributaries there are other equally large areas
devoid of any irrigation whatever beyond what is obtained from wells or other
merely local arrangements.
These great blanks, as it were, in the irrigation system enable one, as we shall
see later, to judge of the effects produced by irrigation upon malaria.
5
CHAPTER II.
Autumnal Epidemic Malaria.
The Punjab has always been looked upon as malarious and though it is so dry
a tract the recorded death rate from fevers is higher than that for most parts of
India.
A marked feature of Punjab malaria is its seasonal character. During the cold
weather months and the very hot weather following them very little rain falls, and
it is not until June when the monsoon sets in that the conditions become favour-
able to the breeding of anopheles.
Whether or not from this cause malaria remains in abeyance in the Punjab
until the autumn when in greater or less degree it becomes prevalent.
The admissions for malaria among troops stationed in unhealthy places in the
Punjab show very regularly an increase commencing in July or even June and
reaching its greatest height in October or November. Investigations at Mian Mir
show that this increase in admissions for malaria is associated with a greater
prevalence of anopheles and a rise in the spleen rate in the native bazaars of the
cantonment. With regard to the infection among troops and the prevalence of
anopheles Wilson1 h a s s h o w n t h e s a m e t h i n g f o r F e r o z e p o r e .
As observations at Mian Mir have now extended over a number of years we are
able to say in regard to this station that there occurs a regular fluctuation in the
level, so to speak, of malaria as shown by the spleen rate and parasite rate.
This level is lowest during the months of June, July and rises highest in Octo-
ber, falling again during the winter months.
If we examine the mortality records of the Punjab we shall be struck by an
almost exact repetition in most years of this curve. Especially before plague
appeared and so profoundly modified the seasonal prevalence of deaths we find
the number of deaths lowest in June and July, rising in September, highest in
October and November and falling again through the early months of the year.
In a paper attached to this report2 i s g i v e n t h e r e s u l t o f a p r e l i m i n a r y s t u d y
of the mortality statistics with reference to the investigation of epidemic disease.
The principle made use of depends upon the fact that if for any given community
the number of total weekly or monthly deaths is plotted out in the form of a curve
this will maintain an approximately level line except when epidemic disease makes
its effects seen in the form of an "epidemic rise." This result of epidemic disease
in India is so enormous that we can study records of its effects even should our
1 Wilson : Notes on the fevers prevalent at Ferozepore in the Punjab.— Jour. Royal Army Medical
Corps, No. 6, June 1909.
2 Christophers : Suggestions on the use of available statistics for studying Malaria in India.— Paludism,
No 1, July 1910.
6
statistics not be absolutely accurate, the epidemic in such cases causing a mortality
out of all proportion to that of non-epidemic times; we can in fact, study a death
curve with its periodical epidemic rises as dispassionately as we could the record of
a seismograph or other recording instrument.
A very remarkable feature of these epidemic rises in the Punjab is the
regularity with which those due to a particular disease tend to occupy a certain
definite portion of the year. Another feature is that the form of the curve tends to
be characteristic of particular diseases, the curve for cholera differing in character
from those due to either plague or malaria.
In such a study we are not dependent on the diagnosis of the returns of deaths.
which obviously are open to grave fallacy, though we use these in helping us to
interpret the curve.
Studying mortality curves from different areas of the Punjab in this way we
shall be greatly struck by their similarity.
During March, April and May we may encounter during latter years an enor-
mous rise, the effect of epidemic plague. In those year's in which plague is not
prevalent we shall find either a normal level maintained or slight rises associated
with smallpox and other epidemic disease. About August there often occurs a
remarkably sharp and sudden rise. A study of returns shows this to be the effect
of cholera. Still later in October and November we come to another rise usually
shaped like a truncated cone but rising more abruptly than it falls.
This epidemic rise in the autumn is extremely characteristic of death returns.
from the Punjab. It is seen in the death curve of almost every town and thana
except in those exceptionally situated in desert regions such as the Thal; in charts
of most places scarcely a year is seen which does not show it to a greater or less
extent (vide Chart 1). 1 Examining the records it is rare that any other cause than
"fever" can be found to account for it and even if other epidemic diseases are
prevalent their incidence is out of all proportion to the immense mass of deaths
ascribed to fever. If we examine the curve as shown at different places we shall
see that it varies very greatly in height and that it is highest as a rule in those
places noted for malaria. Again if year by year in any particular place we follow
the variations in the height of the autumnal epidemic rises we shall see that they
are highest in the years noted as most malarious.
When well developed the autumn epidemic rise exhibits very specific charac-
ters, it rises abruptly in September, maintains its greatest height through October
and November and sinks rapidly to December and through January to normal.
In years in which the rise is small the curve is often more acutely pointed and may
be delayed so that the highest point i s reached in November or even in December,
1 All the maps and charts illustrating this report will be found in a pocket attached to the back cover.