NationalLibraryOfScotland/medical-history-of-british-india huggingface dataset:
64
Christophers in Africa, is characteristic of the infection of native children, and
if they are seen in the mornings (which is the usual time at which one goes
out to take specimens of blood), it would certainly be difficult to say from their
appearance that any of the children were suffering from malarial fever.
In the evenings one or two of the children may be lying down, others,
however, though evidently suffering from fever, may be still playing about with
the other children of the village, and the parents are seldom aware that their
children are not in good health.
The following cases were first examined for a few days in February and
again for a period of a week during March.
INFECTION OF NATIVE CHILDREN.
Case I.
Nance.—Palaythan. Age.—6 years.
First seen on the morning of February 23rd. He looks a moderately
healthy child and his parents consider him to be quite well. His spleen, how-
ever, is enlarged one hand's breadth below the costal margin.
8 A.M., 23rd February 1902.—A few full-grown asexual Quartan parasites
found.
5 P.M., on the same day (temperature 103°) two segmenting Quartan
parasites and several pre-segmenting forms. No gametes. The child has
apparently not felt any chilliness throughout the day, and though his skin
feels hot, he is still playing about and is to all appearances little, if at all, incon-
venienced by the fever.
DATES OF OBSERVATIONS.
65
24th February 1902.—Negative after a short examination.
25th February 1902.—A few asexual forms (Quartan) nearly filling the
corpuscles. No evident symptoms.
9th March 1902.—The slide on this date contained a large number of nearly
full-grown Quartan parasites. No gamete forms seen.
10th March 1902, 5 P.M. (temperature 103.4°).—A number of pre-segment-
ing and segmenting forms and in the same slide several forms which have the
appearance of gametes. It is difficult, however, in a stained slide, to distinguish
between a full-grown asexual Quartan and a gamete, so that, as I did not
examine fresh specimens as well, I am unable to say whether gamete forms
were really present in this case or not.
13th March 1902.—Segmenting forms were again seen in the slide at
5 P.M. on this date.
Throughout my examinations of this case, the child appeared to be very
little affected by the fever, which lasted for only a few hours every fourth day.
An examination of the chart and of the above notes will show, however, that
this was an ordinary and very regular case of Quartan fever.
Case II.
Name.—Mooragan. Age.—5 years.
This child is very thin and evidently weak. His spleen is enlarged more
than one hand's breadth below the costal margin.
DATES OF OBSERVATIONS.
66
23rd February 1902.—A scanty infection with small and large asexual
Quartan parasites. The blood was not examined again until the 9th March,
when scanty full-grown asexual forms were seen.
.
11th March 1902.—Two segmenting Quartan parasites and a few forms
which were certainly gametes were seen.
.
14th March 1902.—The slide contains a few gamete forms. No asexual
parasites seen.
The infection in this case had evidently undermined the health of the child
considerably. He had not, however, been sufficiently ill to prevent his walking
about or taking food.
Case III.
Name.—Migammah. Age—4 years.
This case was first seen on March 9th. He appears a well-nourished
child. Spleen enlarged two inches below the costal margin.
MARCH
This case shows very well the results of a mixed infection with Quartan
and simple Tertian parasites
4 P. M., 10th March 1902.—A large number of full-grown simple Tertian
67
parasites, some of which were in the pre-segmenting stage, and a fair number of
segmenting Quartan parasites were found.
11th March 1902.—A slide at 5 P.M. contained many medium sized-simple
Tertian parasites, and Quartan parasites about ¼th the diameter of the corpuscles.
12th March 1902, 5 P.m.—One segmenting Tertian and a large number of
nearly full-grown Quartan. A fair number of gamete forms.
13th March 1902, 4 P.M.—Several segmenting Quartan parasites and a
few young simple Tertian parasites were seen. Many gamete forms.
Throughout the examinations of this case, gamete forms were present in fair
numbers; and in an examination of fresh specimens on 14th March 1902,
several flagellating bodies were seen.
It is remarkable in this case that, in spite of the large infection and the
high temperatures, the child appeared fairly well and, according to the statement
of its parents, took its food heartily.
Case IV.
Name.—Perumal. Age.—1 2 years.
A well-nourished boy whose parents said he had had fever every fourth day
for over three months. Spleen enlarged to the level of the umbilicus.
DATES OF OBSERVATIONS.
K 2
68
This was a case of a heavy infection with Quartan parasites, which went
through their cycle with great regularity. The symptoms were more marked
than in any of the other cases examined, but, except on his "fever days'' he felt
quite well and was accustomed to go out in the fishing boats with his father.
The paroxysm began with a chill and slight shivering about three o'clock in the
afternoon. By five o'clock the temperature had reached its height and the
paroxysm ended with profuse perspiration between six and seven o'clock in
the evening, after which he felt practically quite well for the next two days.
Case V.
Name.—Vadyvaloo. Age.—5 years.
Although this child was able to run about with the other children, the
physical signs were very marked. His face, body and legs were swollen and
œdematous, his spleen was enlarged beyond the level of the umbilicus and his
blood was so thin and "watery" as to make it difficult to prepare films from it.
MARCH.
The blood examinations showed scanty infection with at least two groups
Quartan parasites.
11th March 1902.—A fair number of asexual forms from ¼th to ½ the
diameter of the corpuscles together with a few segmenting forms were found.
MARCH
MARCH
Chart for Case VI.
Chart for Case VII.
69
13th March 1902.—In an examination of fresh specimens to-day, two flagel-
lating bodies together with a few large asexual forms were seen.
Case VI.
Name.—Chinnapan. Age.—7 years. Spleen palpable.
This was the only case of a pure infection with simple Tertian parasites of
which I was able to get a temperature chart. The infection was a scanty one.
In the mornings, the child appeared perfectly well, but on the evenings of his
fever days he was usually to be found lying down wrapped up in a blanket.
Case VII.
Name.—
. Age.—9 months. Spleen 1 inch below costal margin.
This case is interesting as showing infection in a young baby. A fair
number of asexual Quartan parasites were found. The mother did not know that
her child was suffering from fever
.
ti
70
Case VIII.
-
Name.—Iyahcanoo. Age.—10 years. Spleen three inches below the costal
margin.
DATES OF OBSERVATIONS.
On February 23rd a mixed infection with simple Tertian and Quartan para-
sites was found.
On March 9th only one medium-sized Quartan parasite was seen after a
long search, and after this date parasites were absent from the peripheral circula-
tion. A considerable increase in the proportion of large mononuclear
l e u c o c y - t e s ( a n i n d i c a t i o n o f r e c e n t i n f e c t i o n ) r e m a i n e d u n t i l t h e e n d o f t h e e x a m i n a t i o n s .
An evening rise of temperature was noted in four out of six other children
whose temperatures were only taken once.
I have unfortunately not had an opportunity of following out any cases of
malignant Tertian infection in children, but it may be noted that, although we
have frequently observed crescents and occasionally crescent derived spheres, in
the slides of blood from infected children, the spherical form of the malignant
Tertian gamete, which was noted by Drs. Stephens and Christophers as charac-
teristic of the infections of African natives, has never, so far as I am aware, been
seen by any of us in India.*
* I have lately had an opportunity of following out several cases of infection with malignant Tertian
parasites in babies and young children ; during the periods when asexual forms of the parasites are present
in the peripheral circulation the symptoms are more marked than in the case of Quartan and simple Tertian
infections. The gametes are of the usual crescentic shape and character.
71
A consideration of the above cases will show, I think, that there is really no
essential difference between child infections and those occurring in adults. The
same febrile disturbance takes place about the time of segmentation of the para-
sites, and the asexual forms go through their cycle with the same regularity
as is usually observed in an untreated case of malarial fever in an adult.
It is certain, too, that although the children appear fairly bright and well on
a casual examination, the frequent attacks of fever and the continued infection
with parasites for many months, undermine their health to a very great extent
and result in the same after effects, viz., marked anæmia, enlarged spleen, and
sometimes œdema and dropsy, as would be observed in untreated cases in
adults.
It is evident, therefore, that unless the malaria of native children in India
differs markedly from that of the African children, the statement that native
children may harbour the parasite in abundance and yet be free from fever and
cachexia,* requires modification.
The well-recognised fact that young children are much less affected as
regards clinical symptoms by even considerable rises of temperature than adults,
is sufficient, I think, to account for their symptoms being easily overlooked,.
unless the children are carefully watched throughout a period of some days.
* " The Practitioner," Malaria number, March 1901. Page 259.
73
III.—OBSERVATIONS ON THE CAUSES WHICH INFLUENCE THE
PREVALENCE OF MALARIA IN DIFFERENT PARTS OF INDIA.*
W E have seen that the amount of malaria and the liability to infection (of
which we have taken the " Endemic Index " to be the best test) varies
greatly in different parts of India, and it becomes necessary to enquire therefore
what are the causes which bring about such great differences in the endemicity
of different places.
We may divide the districts we have examined into areas of high ende-
micity, such as the Bengal Duars, the Terai, and the Jeypur hill districts, and
areas of low endemicity, such as Calcutta and the plains of Bengal.
I. We shall consider first the influence of anopheles mosquitoes on the
endemicity of malaria.
Under this heading we may divide our observations as follows :
—
(1) The influence of the presence of breeding grounds.
(a) The extent of the breeding grounds.
(b) The distance of the breeding grounds.
(2) The influence of the abundance of adult anopheles.
(3) The influence of the presence of particular species of anopheles.
(1) The influence of the presence of breeding grounds on the amount of
malaria may be well illustrated from the examination of a number of villages
in the Central Provinces. Here we were able to find several types of villages ;
one type, for example, with very extensive breeding grounds close at hand,
another with extensive breeding grounds at a greater distance away, a third with
no breeding places nearer than half a mile, and a fourth the nearest breeding
places to which were at a greater distance than half a mile.
* I am indebted to Drs. Stephens and Christophers for the general plan and much of the material of
this chapter.
L
74
The following table, therefore, shows the relation between the .distance and
extent of breeding grounds, the number of anopheles and the amount of
malaria:—
TABLE I.
Name of village.
Endemic index,
per cent..
Spleen rate,
per cent.
Species and abundance
of anopheles.
Distance and extent
of breeding grounds.
Phutala
45
50
A. Culicifacies.
A. Fuliginosus, very
abundant.
Less than 50 yards;
extensive.
Sakadara
1 5
15
A. Rossii.
A. Fuliginosus, not
very abundant.
Less than 50 yards;
not extensive.
Digdoh
20
25
A. Culicifacies, very
abundant.
100 yards.
Seendra
2 0
o
A. Culicifacies.
A. Fuliginosus, abun
dant.
200 yards.
Ambigheri
25
A. Fuliginosus, abun
dant.
A. Culicifacies, scanty.
200 yards.
Anjini
25
40
A. Culicifacies.
A. Stephensii.
A. Fuliginosus, very
abundant.
One-fourth mile; very
extensive.
The above examples may be considered as type I where the breeding
grounds are near, anopheles are fairly abundant and the endemic index is high—
the variations in the amount of malaria (e.g., Sakadara) being due chiefly to
differences in the extent of the breeding grounds.
The following is an example of type II, where there are no breeding places
within half a mile :—
Soonegaon.
8 per cent.
o per cent.
A. Stephensii, scanty. No breeding places
within half a mile.
The following are examples of type III, where the breeding places are over
half a mile distant :—
Lawa.
Wadi
5 per cent.
5 per cent.
o per cent.
o per cent.
Nil
Nil
Over half a mile.
Ditto.
In addition to the above types of villages in which the prevalence of malaria
75
easily explained by the varying distance and extent of breeding grounds, it is
possible to find villages with a considerable amount of malaria and yet a variable
number of anopheles, sometimes indeed with much malaria and no anopheles at
all, nor any breeding grounds near at the time of examination.
The cycle of events which has been gone through in such cases as this is
as follows :—
Firstly, the presence of many small shallow rain-formed pools with
numerous anopheles .
Secondly, the drying up of these pools and the consequent extinction of
all breeding places, but yet with the continuance of the adult
anopheles n the houses.
Thirdly, the disappearance of the adult anopheles but yet with continuance
of the infection in the children.
It is at this third period when a good deal of malaria is found in the children
of a village, and yet no adult anopheles can be found in the houses, and no
breeding places are present, that, unless the above cycle of events is remembered,
the presence of malaria seems difficult to explain.
That this explanation is the correct one is well shown in the, following
table :—
TABLE II.—To SHOW CONTINUANCE OF ADULT ANOPHELES AFTER BREEDING GROUNDS HAVE DRIED
UP, AND THE CONTINUANCE OF RESIDUAL MALARIA IN THE CHILDREN AFTER
DISAPPEARANCE OF ANOPHELES.
Place.
Date.
Endemic
index,
per cent.
Spleen
rate,
per cent.
Anopheles in the
houses.
Breeding places
at time of
observation.
Signs
of breeding
grounds
some time
previously.
Mian Mir Bazaar
September
52
80 Abundant A. Culici-
facies and A. Rossii
Present.
Yes.
Ditto
October
35
75 Scanty A . Culici-
facies, abundant A.
Rossii.
None
Yes
Ditto
December
29
34
None found
None
Y e s
Mian Mir, Syce Lines October
56
48 Abundant A. Rossii
and A. Culicifacies.
Present
Yes.
Ditto
December
12
3 0
None found
None
Yes.
Tapara village
...
27
36
Scanty
None
Yes.
Fishing village, Viza-
gapatam District.
...
1 0
17
Very scanty
None
Y e s .
L 2
76
In places such as the following where no adult anopheles are found n the
houses, no breeding places are present and there are no signs of breeding places
having existed at some time previously, we find no malaria to be present in the
children.
Place.
Endemic
index,
per cent.
Spleen rate,
per cent.
Anopheles
in the houses.
Breeding places
at time of
observation.
Signs of breeding
places at some
time previously.
Vizagapatam Busty
•
•
0
0
None found
Nil
Nil
Chintarapelly
•
•
.
0
0
None found
Nil
Nil
(2) The influence of the number of adult anopheles.—Three types of villa-
ges may be found which show the influence of the abundance of adult anopheles
on the amount of malaria. These are as follows :—
(1) Villages with no adult anopheles and no malaria. Examples of this
type of village are Wadi, Lawa and Chintarapelly (the endemic
indices, etc., of these villages have been given previously).
(2) Villages in which the anopheles are more or less abundant and the
endemic index varies accordingly. Many examples of such places
will be found in the tables already given.
(3) Villages in which the anopheles are scanty or absent and yet the
endemic index is often high. The explanation of this and examples
to illustrate it have already been given.
In addition to the above types of village the amount of malaria in which
can be easily explained, there is another class of place of which Calcutta may
be taken as the type in which there are abundance of anopheles, numerous breed-
ing grounds close at hand and apparently every condition favourable to the
development of malaria, and yet no infection is found in the children and no en-
larged spleens. At Calcutta two districts which were reputed to be most un-
healthy were chosen for work, viz., the:district of Hastings and that adjoining
the Circular Road. In these districts all the conditions appeared most favourable
for the development of malaria. The native population was crowded together in
huts on low-lying flat ground which was, at the time of our visit, for the most part
covered with water and surrounded by pools and tanks. The temperature was
constantly high, and anopheles abounded. The Commissioners of the Royal
Society are of opinion that not even in the worst fever districts of Africa have
they met with anopheles in such abundance. In every house which we entered
anopheles in large numbers could be caught with ease at any time. Under such
conditions one would have expected much malaria to prevail.
77
On the contrary, however, we found that none of the 140 children examined
by us had parasites in their blood, none of them had enlarged spleens, and not one
of the 324 anopheles dissected was infected. At the end of September, which
is considered to be the time at which fever is most prevalent in Calcutta, 42
children from the same districts were again examined with the same result, none
of them showing parasites in their blood and none enlarged spleens.
One must conclude, therefore, that in these districts, in spite of the enormous
number of anopheles, there is practically no endemic malaria, and the danger of
infection is almost nil. In the Duars, on the other hand, the number of anopheles
was not nearly so large—it was in fact often a difficult matter to catch a sufficient
number to obtain the correct infection rate. The endemic index in this district,
however, varied from 40 to 70 per cent. It is possible, therefore, to have a very large
number of anopheles in a place without any malaria, while in another place with
fewer anopheles there may be a large amount of malaria, so that it is unwise to
make deductions regarding the prevalence of malaria in different places from
observations on the relative number of anopheles in each place. Another place
where anopheles were found in large numbers without the presence of any infec-
tion in the children and without any enlarged spleens was the village of Salur in
the Madras Presidency. There is no satisfactory explanation for this condition
of things, but, excluding these peculiar instances, we may say that a direct relation
exists between the extent and nearness of breeding grounds, the abundance of
anopheles and the amount of malaria.
(3) The influence of the presence of particular species of anopheles.—Practi-
cally the only species of anopheles which was present in the parts of Calcutta
examined by us was A. Rossii. The mere fact that a species of anopheles
could exist in such large numbers without producing any infection in the
children was in itself suggestive that the species was not a good carrier of
malaria.
A reference to the table of the Infection of Native Children (page 60) will
show that as we proceeded from Calcutta through the plains of Bengal to the dis-
trict known as the Duars, at the foot of the Himalayas, the endemic indices gra-
dually increased from nil in Calcutta to as high a rate as 72 per cent. in the Duars.
It was a significant fact that on reaching the areas of higher endemicity we en-
countered two new species of anopheles which we had not previously seen in India.
One of these (viz., A. Maculata, Theobald) was present only in scant numbers, the
other (viz., A. Fluviatilis= A. Christophersi, Theobald) was fairly common in the
coolie huts of the tea plantations in the Duars. This species resembles in many
respects and is possibly identical with the African species, A. Funestus (Giles),
which has been proved to be responsible for so much of the malaria in Africa.
Although we had not been able to find infection in any of the large number of
rig
78
A. Rossii we had previously examined, infection with sporozoites to the extent
of 6.25 per cent. was readily found in this new species. It was evident that this
new species was the carrier of malaria in the Duars, and in none of the A. Rossii
which we examined there did we find infection. Very few A. Rossii, however,
were found in the Duars, and we were not able to obtain sufficient numbers to
make the point certain that it was not also carrying malaria as well as
A. Fluviatilis.
From Calcutta to the Duars the places were under practically identical
conditions—similar climatic influences, a uniform high temperature, an abundant
rainfall, and much surface water. In Calcutta, however, we had abundant
A. Rossii and no malaria, and in the , Duars a relatively small number of
A. Fluviatilis and a large amount of malaria.
It appeared probable, therefore, that the question of species was an important
one in connection with malaria, and that whereas A. Fluviatilis was an exceedingly
good carrier of malaria, A. Rossii was a very inefficient one.
This probability received confirmation in a remarkable way in two other
places which we visited, viz., Mian Mir in the Punjab and Ennur in Madras.
In one of the bazaars at Mian Mir we found the children to be infected with
parasites to the extent of 50 per cent. In this bazaar two species of anopheles
were common, viz., A. Rossii (Giles) and A. Culicifacies (Giles). A. Culicifacie
s
species which belongs to the same class and resembles, in some respects,
A. Fluviatilis of the Duars. Both species, A. Rossii and A. Culicifacies,w e r e
almost equally prevalent in the bazaar at Mian Mir, and we were thus able to
catch a sufficient number of both species at the same time and in the same house
to compare infection rates.
The following was the result of our dissections :—
Species of anopheles.
Number dissected.
Percentage infected with sporozoites
in the glands.
A. Culicifacies...
259
4.6,
A. Rossii.
4 9 6
Nil
It was practically certain therefore that in this bazaar A. Culicifacies was
carrying malaria while A. Rossii was not.
The third place where we were able to show that A. Rossii was not carrying
malaria under natural conditions, was at Ennur, a fishing village about ten miles
from Madras. I visited this place in February and found the children to be
infected with parasites to the extent of over 50 per cent. A. Rossii was present in
very large numbers and A. Culicifacies somewhat scantily. In spite of its being