NationalLibraryOfScotland/medical-history-of-british-india huggingface dataset:
125
when the zygotes have matured and the sporozoites have reached the salivary
glands, only a very few of the salivary cells are packed with sporozoites; it is evident
that such a mosquito feeding on a bird will inject at the most a comparatively small
number of sporozoites.
Some of the experiments suggest that in this case one may use large numbers
of mosquitoes without producing much result. But in mosquitoes fed on a bird
whose blood contains very numerous gametes, the mid-gut is studded with hun-
dreds of zygotes and when the sporozoites have reached the glands these become
swollen with innumerable multitudes of sporozoites. Such a mosquito must
inject a dose perhaps a hundred times greater than one of the slightly infected
mosquitoes we have referred to.
Using scantily infected mosquitoes even in great numbers it is difficult to get
a severe infection ; single heavily infected mosquitoes on the other hand often give
quite severe infections. But by using a number of heavily infected mosquitoes
not only was the incubation period reduced from nine days to as little as five
days, but the resulting infections were much more severe and death in every case
occurred.
The last two experiments show that when a bird already having parasites in
its blood is bitten by heavily infected mosquitoes it still developed a new infection
over and above the old one.
The amount of infection carried by mosquitoes then depends on the number
of zygotes which develop in the gut, and the number of these in turn depends upon
the number of gametes in the blood of the sparrow by which the mosquito has
become infected.
It is easy therefore to see that in malaria everything may depend upon the
existence of heavy gamete carriers ; and if these are present upon the number of
anopheles : otherwise the relation of number of anopheles to the amount of fever
will not hold good.
127
PART
V.
Summary of Conclusions.
Briefly recapitulating the facts recorded in the earlier parts of the paper we
can summarise the results of our observations as follows :
—
(1) Malaria in the Punjab is manifested in two ways, namely as "endemic
malaria" and as " autumnal epidemic " or " fulminant malaria."
(2) Economically the latter is by far the most important and it is the effects
of this form which are usually referred to when the disastrous results
of malaria in the Punjab are spoken of.
(3) The epidemic of 1908 was of this character and there have been similar
and almost if not quite as severe epidemics at intervals at least as
far back as the sixties.
(4) These epidemics are focal, that is, their effects are greatest in the centre
of the epidemic area and fade towards the periphery. Their distri-
bution vividly calls to mind such phenomena as areas of low or
high barometric pressure and not at all that of a disease following
lines of communication or even local peculiarities of the ground.
(5) The history of past epidemics shows that they affect all parts of the
submontane tract but have shown a special frequency over certain
areas. In 1908 there existed for the first time two distinct major
epidemic areas, the southern one producing epidemic effects also
over the western half of the United Provinces.
(6) Epidemic malaria attacks most severely those communities which
already show a high degree of endemic malaria. It is therefore
not merely the result of malaria attacking those unaccustomed to
the disease nor are endemic areas in any way protected against it.
(7) The most salient feature of the epidemic condition is the excessive
mortality and its conspicuously infantile character.
(8) The condition of a population in the Punjab as regards natural increase
or decrease is influenced rather by the number and severity of the
epidemics to which it has been exposed than by its endemic malaria.
Even the effects of famine are mainly shown through the effects of
the epidemic malaria which follows them.
(9) Town and cities suffer equally with, even in some cases more than,
rural areas, and even the centre of the large cities, Amritsar and Delhi,
are only moderately protected from epidemic effects.
(10) The determining causes of epidemics are excessive rainfall and scarcity ;
the former is an essential whilst the latter is an almost equally power-
ful influencing factor. Owing to the meteorological cycles there is a
128
tendency for epidemics to occur at the point where the first heavy
monsoon appears after a succession of years of deficient rainfall.
(11) The epidemic areas are not necessarily or even usually coincident with
that of the heaviest rainfall nor that receiving the greatest increase
over the normal rainfall. Any marked relation to " interval "
between the falls, etc., is not suggested by a study of the rainfall
figures. The whole facts are only explicable when flooding is taken
into account.
(12) When epidemic areas are examined in detail the villages are found to
have suffered almost exactly in proportion as they have been
flooded. Floods act equally whether they are due to local rain or to
the indirect effects of rain causing the overflow of rivers. The
higher epidemic figures seem to depend entirely upon floods and
fulminant malaria of a certain intensity is almost synonymous with
malaria of diluvial crigin. The relation to flooding explains why
epidemic areas are not exactly coincident with the area of heaviest
rainfall and why the former almost always overlaps the latter in the
direction of the line of drainage.
In the case of lower epidemic rates the thana figures may be influenced in two
ways—
( 1 ) B y t h e n u m b e r o f v i l l a g e s s h o w i n g " f u l m i n a n t " m a l a r i a .
( 2 ) B y t h e n u m b e r o f v i l l a g e s s h o w i n g a m o d e r a t e r a i s i n g o f t h e m o r t a l i t y .
Whilst the very severe manifestations of fulminant malaria seems to be
dependent on floods, epidemic malaria seems to reach a certain intensity apart from
floods in the sense we are now using this term. But the conditions at Mian Mir
and other observations suggest that even here something very like flooding occurs
in so far as extensive sheets of water are formed.
(13) The exact mechanism of epidemic causation is still unknown. But
the epidemic condition appears to be due to an excessive seasonal
increase of the normal parasite rate, fluctuations in which occur even
in healthy years.
Malarial infections must be studied quantitatively. An endemic index of 100
per cent. may be represented in one case by a community containing only a
few parasites in their blood and living in a condition of comparative health, in
another case the index may refer to a community heavily infected and prostrated
by fever.
In the Punjab one frequently hears matters discussed as if the population was
uninfected and remained so until the fever season came round when any individual
was more or less liable to catch infection. It is nearer the truth to say that we have
129
a population already infected and that what happens in the fever season is the
" hastening up " of this infection.
(14) Experiments on sparrows and proteosoma show that severity of infec-
tion is largely dependent on the dose inoculated. This is not merely
a matter of the number of infected mosquitoes but of the number of
sporozoites injected at each bite. This in turn depends upon the
number of gametes in the blood of the original sparrow by which
the mosquito was infected. Under experimental conditions the
latter was the most important factor and it was easy to see as a
result of dissection that one heavily infected mosquito might inject
more sporozoites than a hundred that were only scantily infected.
No observations exist as to the conditions in regard to anopheles at
epidemic times, but the close association of fulminant malaria with
actual flooding suggests something more than the ordinary reproduc-
tion of the genus in pools, etc. The matter is the most urgent still
awaiting elucidation.
( 1 5 ) P h y s i c a l f e a t u r e s i n f l u e n c e e p i d e m i c s a n d l o w w a t e r - l o g g e d a r e a s a r e
especially susceptible to epidemic conditions. Higher tracts, on the
contrary, are comparatively less susceptible. But these differences
are often lost when a district becomes involved in the nucleus of an
epidemic area.
( 1 6 ) T h e g r e a t c a n a l s y s t e m s h a v e n o d i s t i n c t i n f l u e n c e u p o n m a l a r i ao
f
this kind, though it is possible that neglected canal irrigation with
extensive local floodings may have had very serious effects in the
past.
131
PART
VI.
Conclusions on the Chief Methods to be Advised in the Prophylaxis of
Malaria in the Punjab.
An elaborate discussion as to the methods of prophylaxis in malaria would be
out of place in the present work. It is necessary only to call attention to the more
important considerations called forth as a result of the present investigation.
The subject of prophylaxis among Troops, Jails and European communities
is also outside the scope of the present report which has dealt throughout with the
fundamental conditions as shown by malaria of the native population.
Rural Areas.
Endemic Malaria in Rural Areas. —A high degree of malaria is a common
character of almost all rural populations in the Punjab. Even the healthiest
villages show rates which in contrast with those quoted for Egypt must be
considered high. This amount of infection is not always associated. with a very
obvious proportionate prevalence of anopheles and even when closely investigated
is found to depend to a large extent upon conditions in regard to the anopheles
factor whose chief character is their temporary and even fleeting nature. It thus
happens that villages and towns are most frequently seen under conditions
which, if they were to continue uninterruptedly, would probably be associated with
much reduced prevalence of malaria. In all operations directed against malaria in
villages we have to bear this in mind, nor is it in the present day sufficient to
locate a few sources of anopheles to explain the existence or the degree of malaria.
If in a malarious village there are only a few sources of anopheles at the time of
some particular visit the probability of there being an enormous number at some
other time of the year is very great. For a reduction of this endemic malaria
we require a greater and more detailed knowledge of the conditions influencing it
both as regards any measures in the nature of drainage (other than the drainage
we shall refer to later of special nature) or of quinine prophylaxis.
It is not at all certain which are the most important sources of anopheles in
many rural areas, whether pits and excavations are in themselves largely or only
in a minor way concerned, and the whole matter is too uncertain for specific re-
commendations yet to be made. Also this aspect of the matter is less urgent than
that which we have next to consider.
Fulminant Malaria in Rural Areas. —The terrible effects of an epidemic are
greatly in excess of anything that results from the normal endemic conditions. And
even though the death rate is raised by endemic malaria, the effect of epi-
demic conditions is vastly larger and more important. Of the effects of epidemics
s 2
132
we may distinguish various degrees. The effects of the first degree are such as
caused consternation at Amritsar and such as anyone visiting the villages can see
was equally exhibited over the country. My own impression supported by facts
already given in the descriptions of epidemic areas is that this high degree of
epidemic intensity is almost if not entirely a matter of villages being flooded.
What the action of the flood waters may be, does not at present concern us. If
there are no flooded villages in a thana the total death rate will at most only
be moderately increased. In the controlling of floods we have then one very
clear objective and one which is within some measure of possible attainment.
The controlling of floods must often be a matter of drainage, but such
drainage must not be confused with drainage of the soil which, though it may often
be affected in the same way, is a much larger question. In Gujrat flooding is largely
a matter of overflow of rivers and here extensive bunds are called for and their
construction has in some cases been carried out.
The beneficial results likely to follow immediate removal or prevention of flood
water are so great that there seems little doubt that in the Punjab this should
be the first step in the sanitation of a rural tract, especially tracts known to suffer
from the effects of such conditions.
Drainage in the sense of a system of surface drains or of subsoil drainage is
a matter we need not now enter upon. Under the circumstances present in India
it can only be carried out in a limited manner. If we seek to avert epidemic
malaria by such means we have 50,000 square miles to treat before we have the
zone of epidemics under control.
It is more important to point out that the facts regarding the influence of
subsoil water and the conditions relating generally to the occurrence of the
second and third degree of epidemic intensity are still very imperfectly known.
Measures of a detailed anti-larval nature are not indicated and as in Mian
Mir they probably would not serve to protect the inhabitants in the very year in
which this would be necessary.
If as seems to be the case severe epidemic malaria follows flooding, the most
energetic anti-mosquito campaign can influence but little the vast mortality
which may occur in any year in almost any district. That under these circum-
stances, until drainage can be instituted, the use of quinine as a prophylatic and as
a means of saving the life of actual sufferers must be pushed to the utmost, is self-
evident.
Small Towns of the Punjab.
Nothing can be more striking than the way these towns, often extremely
compact and. apparently unlikely to be affected by malaria, have been penetrated
to their centre by epidemic conditions. It is extremely doubtful if the origin
of these conditions is to be found within the actual limits of the town and any
133
scheme to prevent the disastrous effects of epidemics must be prepared to take
into count at least the immediate surroundings. Very often as at Bhera these
surroundings strike one as not being very easily controlled, but it is probable if
hydraulic measures were considered as of prime importance a good deal might be
done. Here as in the rural areas the urgency of quinine organisation cannot be
exaggerated.
Cities of the Punjab.
The conditions at Amritsar were so severe that the desirability of protecting
so important a city is very evident.
Amritsar is already drained in a fashion and the question arises as to what
are the various degrees of drainage we may employ. The crux of the whole
question lies in the fact that as a rule those places which it would be compara-
tively easy to drain are drained and are not malarious, whilst such places as Amritsar
impose great obstacles to proper drainage. The slope of the Punjab in this region
is about 1 foot per mile. To find a vent efficiently to carry off flood water from the
great depressions around the city of Amritsar, must mean, a main drain at least
some 20 miles in length. To fill in a small fraction of the land. (197 acres)
around the city took 8 years (1884—1892) and cost Rs. 2,56,568 ; the filling in
of the depressions would therefore be a very great undertaking.
Within the city boundaries on the west there are areas of waste land and
excavations which could be drained with an efficient outfall, but which could
scarcely be dealt with without this provision. There are also public and private
gardens to be considered.
Conditions around the immediate periphery of the city as regards the
breeding of anopheles could be greatly improved. There are also many parts
within the city that could be rendered safe as regards the breeding of anopheles,
at a moderate cost. Intramural measures would probably increase the protection
of the more central portions and perhaps narrow the peripheral zone of high
intensity. The important point is to combat the conditions that are apt to arise in
very heavy rain; otherwise efforts are likely to be stultified by as severe an
epidemic as ever making its appearance.
At Delhi closure of the large disused wells should be a measure to be under-
taken at once, but apart from this a great deal has still to be worked out before
really responsible recommendations could possibly be given.
In conclusion, I wish to acknowledge the great assistance I have received
throughout from my laboratory staff, especially from Hospital Assistant Khazan
Chand to whose untiry energy and zeal I am largely indebted for much tedious
work connected with abstracting mortality and rainfall figures and whose assist-
ance in Amritsar City and in the villages has been invaluable.
134
Appendix. ( Vide Chapter XIII.)
197
Year.
Fever
deaths
in ten
thou-
sands.
Rain-
fall.
Prices.
Coeffi-
cient.
Rain-
fall
x
Coeffi-
cient.
Prices
x
Co-
efficient.
Rain-
fall
x
Prices.
Rain-
fall
x
Prices
x
Co-
efficient.
1868 .
.
. . .
3.11
10.7
25
1.0
10.7
25.0
26.75
26.75
1869 .
.
.
.
.
11.65
18.1
32
1.6
29.0
51.2
57.92
92.67
1870 .
. . . .
8.05
15.6
28
0.9
14.0
25.2
43.68
39.31
1871 .
.
. . .
3.82
14.2
16
0.9
12.8
14.4
22.72
20.45
1872 .
. . . .
8.24
22.0
20
1.6
35.2
32.0
44.00
70.40
1873 .
. . . .
5.81
18.1
16
0.8
14.5
12.8
28.96
23.17
1874 .
.
. . .
4.42
16.9
12
0.9
15.2
10.8
20.28
18.25
1875 .
. . . .
8.45
27.7
10
1.6
44.3
16.0
27.70
44.32
1876 .
.
. . .
17.42
17.2
10
0.6
10.3
6.0
17.20
10.32
1877 .
.
. . .
3.98
8.5
14
0.5
4.2
7.0
11.90
5.95
1878 .
.
. . .
18.04
18.5
30
2.2
40.7
66.0
55.50 122.10
1879 .
.
.
.
.
14.20
16.6
34
0.9
14.9
30.6
56.44
50.80
1880 .
. . . .
6.81
15.3
32
0.9
13.8
28.8
48.96
44.06
1881 .
.
.
.
.
10.61
18.6
24
1.3
24.2
31.2
44.64
58.03
1882 .
. . . .
9.36
19.0
18
1.0
19.0
18.0
36.20
36.20
1883 .
. . . .
6.12
12.8
16
0.7
9.0
11.2
20.48
14.34
1884 .
.
. . .
1885 .
. . . .
8.16
14.3
10
1.0
14.0
10.0
14.30
14.30
1886 .
.
.
.
.
6.68
18.2
19
1.3
23.7
24.7
34.58
44.95
1887 .
.
.
.
.
13.66
20.6
32
1.2
24.7
38.4
65.92
79.10
1888 .
.
. . .
9.37
17.3
30
0.8
13.8
24.0
51.90
41.52
1889 .
.
.
.
.
11.91
14.9
20
0.9
13.4
18.0
29.80
26.82
1890 .
.
.
.
.
23.46
20.7
26
1.4
29.0
36.4
53.82
75.35
1891 .
.
. . .
8.45
12.3
30
0.6
7.4
18.0
36.90
22.14
1892 .
.
.
.
.
27.32
23.0
33
1.9
43.7
62.7
75.90 144.21
1893 .
. . . .
8.45
23.7
24
1.0
23.7
24.0
56.88
56.88
1894 .
. . . .
14.28
23.1
10
1.0
23.1
10.0
23.10
23.10
135
Appendix. ( Vide Chapter XIII.)
197
Year.
Fever
deaths
in ten
thou- s a n d s .
Rain-
fall.
Prices.
Coeffi-
cient.
Rain-
fall
x
Coeffi-cient.
Prices
x
Co- e f f i c i e n t .
Rain-
fall x
P r i c e s .
Rain-
fall
x
Prices
x
Co-
efficient.
1895 .
. . . .
7.32
15.9
20
0.7
11.1
14.0
31.80
22.26
1896 .
.
.
.
.
6.57
11.2
33
0.7
7.8
23.0
36.96
25.8
1897 .
.
.
.
.
14.16
14.7
35
1.4
20.6
49.0
51.45
72.03
1898 .
. . . .
8.69
13.8
28
0.9
12.4
25.2
38.64
34.78
1899 .
.
.
.
.
6.92
7.5
20
0.5
3.7
10.0
15.00
7.50
1900 .
. . . .
25.46
21.7
35
3.1
67.3
108.5
75.95 235.44
1901 .
.
.
.
.
14.42
12.5
30
0.5
6.2
15.0
37.50
18.75
1902 .
.
.
.
.
9.30
15.2
26
1.2
18.2
31.2
39.52
47.42
1903 .
.
.
.
.
13.53
16.5
15
1.1
18.1
16.5
24.75
27.22
1904 .
.
.
.
.
7.03
10.1
10
0.6
6.1
6.0
10.10
6.06
1905 .
.
.
.
.
6.11
10.1
15
1.1
12.0
16.5
16.35
17.98
1906 .
.
.
.
.
11.51
19.9
35
1.7
32.5
59.5
66.85 113.64
1907 .
.
.
.
.
8.04
11.6
40
0.6
7.0
24.0
46.40
27.84
1908 .
.
.
.
.
30.73
26.3
42
2.2
57.9
92.4
110.46 243.01
Mean
.
.
.
.
11.04
16.6
24
1.07
20.2
28.6
40.2
52.63
Standard deviation
. .
6.3
4.6
9
0.54
14.2
22.3
20.6
52.58
HIMALAYAS
BIKANIR DESERT
THE
PUNJAB
Scale 1 inch = 24 miles
Dotted lines = District boundaries
Unbroken line = 1000 ft Contour
Broken line = 2000 ft Contour
Reg
. No. 3123 E., 11. —H—1,204.
THE EPIDEMIC OF 1892.
HIMALAYAS
B I K A N I R
UNITED
PROVINOVINCES
THE
PUNJAB
Scale
1 inch = 24 miles
Dotted tines
= District boundaries
Unbroken line = 1000 ft Contour
Broken Line
=
2000 ft Contour
MONSOON RAINFALL, 1892.
THE
PUNJAB
Scale 1 inch = 24 miles
HIMALAYAS
BJKANIR DESERT
Dotted lines = District boundaries
Unbroken line = 1000 ft Contour
Broken Line = 2000 ft Contour
THE EPIDEMIC OF 1908.
R e g N o . 3 1 2 3 E . 1 1 —H —1 , 2 0 4 .
B I K A N I R
DESERT
J N
D
PROVINCES
THE
PUNJAB
Scale
I inch = 24 miles
Dotted Lines
= District boundaries
Unbroken Line
1000 ft Contour
Broken. Line
=
2000 ft
Contour
CITY
O F
AMRITSAR
Adult Anopheles
Red crosses
Breedinq Places
Red spo ts
Isospiehic lines
Red
Chart 1. To illustrate "Epidemic Rises" in the line of Total. Death
s.
Reg. No. 3121 E., 11.—V—1.050
Char t 2. Admissions for Malaria Bhera Dispensary.
Chart 3. Mortality during Epidemic of 1908.
Chart 4. Epidemic Mortality.
Chart 5.
Shewing "Fever" mortality (October and november deaths) for
the Punjab
(1867 to 1908).
Chart 6.
To Shew Correlation "Rainfall" with "F e v e r . "
The figures in circles represent prices.
Chart 7.
To skew correlation between "Fever Mortalily" and
Rainfall x Prices. (Col. 8 of appendix)
Chart 8.
Graphic representation of "Intensity as shewn by distribution,
of Classes of Spleer. (The polygon shews distribution of 3134
splens).
Chart 9.
Graphic representation of "Intensity" as shewn by parasite finds.
The polygon shews result of 599 parasite finds.
August
September
October
December
Map 4
To shew distribution of "Mortality in Amritsar City
during the epidemic of 1908
Unshaded areas = epidemic figure under 2.(Twice normal death
rate).
Hatched areas = " " over 2 and Under 5
Cross hatched areas = " " over 5 and under 10
Block areas = " "over 10 (Ten times normal death rate).
Map 5. Plan of Delhi
MAP 6. THANAS OF AMRITSAR AND GHERINDA SHEWING EPIDEMIC
INTENSITY IN VILLAGES
Reg. No. 3122 E.. 11.—H.—1,050
MAP 7.
GUJRAT THANA
SHEWING EPIDEMIC
INTENSITY IN VILLAGES
Map 8.
Map of Bhera and surroundins Thans
Only villages mentioned in the text are named.
T h e f
i g u r e s a r e E p i
d e m i c f i g u r e s
t h e
v i l l a g e s i n O c t o b e r 1 9 0 8 .
MAP9. MAP OF EPIDEMIC FREQUENCY
. M A P S
1_3
IP/QB.10
No. 48
(NEW SERIES)
SCIENTIFIC MEMOIRS
BY
OFFICERS OF THE MEDICAL AND SANITARY DEPARTMENTS
OF THE
GOVERNMENT OF INDIA
INVESTIGATIONS INTO THE JAIL DIETARIES OF
THE UNITED PROVINCES
WITH SOME OBSERVATIONS ON THE INFLUENCE OF DIETARY ON THE
PHYSICAL DEVELOPMENT AND WELL-BEING OF THE PEOPLE
OF THE UNITED PROVINCES
BY
MAJOR D. McCAY, M.B ., M.R.C.P., I.M.S .
Professor of Physiology, Medical College, Calcutta
ISSUED UNDER THE AUTHORITY OF THE GOVERNMENT OF INDIA BY THE
SANITARY COMMISSIONER WITH THE GOVERNMENT OF INDIA
CALCUTTA
SUPERINTENDENT GOVERNMENT PRINTING, INDIA
1911.
Price Rupees 1-12-0 or 3s.
3943159
No. 48.
(NEW SERIES)
SCIENTIFIC MEMOIRS
BY
OFFICERS OF THE MEDICAL AND SANITARY DEPARTMENTS
OF THE
GOVERNMENT OF INDIA
INVESTIGATIONS INTO THE JAIL DIETARIES OF
THE UNITED PROVINCES
WITH SOME OBSERVATIONS ON THE INFLUENCE OF DIETARY ON THE
PHYSICAL DEVELOPMENT AND WELL-BEING OF THE PEOPLE
OF THE UNITED PROVINCES
BY
MAJOR D. McCAY, M.B., M.R.C.P., I.M.S.,
Professor of Physiology, Medical College, Calcutta
ISSUED UNDER THE AUTHORITY OF THE GOVERNMENT OF INDIA BY THE
SANITARY COMMISSIONER WITH THE GOVERNMENT OF INDIA,
CALCUTTA
SUPERINTENDENT GOVERNMENT PRINTING, INDIA
1912