NationalLibraryOfScotland/medical-history-of-british-india huggingface dataset:
18
In severe cases the patient is restless, complaining of want of air and with all
the appearance of an acute hæmorrhage case. A symptom which may be per
- s i s t e n t a n d d i s t r e s s i n g i s p a i n o v e r t h e e p i g a s t r i u m , a n d t e n d e r n e s s m a y b e p r e s e n t
over the spleen, which is nearly always enlarged, and the liver.
Jaundice. At the end of the first twenty-four hours or sometimes earlier an icteric tinge
Urine Examination begins to show itself and rapidly increases in intensity though it never equals in
degree the profound yellow colouration sometimes seen in obstructive jaundice.
The urine which at the commencement of the attack may be light red, resembling
laked and diluted blood, shows on spectroscopic examination the absorption bands
of oxy-hæmoglobin. Later it becomes darker and more brownish in colour, appear
- i n g n e a r l y b l a c k w h e n l o o k e d a t i n b u l k . A f t e r r e m a i n i n g f o r s o m e t i m e m o r e o r
less uniform in tint the urine often somewhat suddenly becomes less intensely
coloured and finally quite free from hæmoglobin. It is common to see in the course
of an attack, especially in those that are severe, one or more periods of exacerba
- t i o n s h o w n b y r i g o r s a n d a d e e p e n i n g i n t h e c o l o u r o f t h e u r i n e . N o t i n f r e q u e n t l y
the urine may clear up only for the hæmoglobinuria to return with a new accessicn
of the symptoms. Along with and after the hæmoglobinuria there is urobilinuria
which continues for some days, Albuminuria which during the hæmoglobinuria
is often sufficient to cause the urine to become nearly solid on boiling continues in a
Blood, less degree for many days after, The blood at first not markedly anæmic even
-tually becomes in a severe case pale and watery, the red cells being sometimes re
-duced to less than a million per c, m„ whilst the hæmoglobin value is corresponding
- l y l o w . V e r y e a r l y i n t h e a t t a c k a f e w m a l a r i a l p a r a s i t e s a r e u s u a l l y p r e s e n t , b u t
later they are not found even after the most prolonged search.
Termina' ions. Recovery If recovery takes place convalescence is rapid, and the patient often has a spell
of better health than before the attack of Black-water Fever, but if he be exposed
to the same conditions as before a second or third attack is only tco liable to follow.
Each time the chances of a fatal termination are very great,
Death. When death takes place it usually follows suppression of urine, the result of a
profound effect upon the kidney epithelium. At other times the enormous blood
destruction itself leads to a rapidly fatal end. Even if the patient pass safely
through the actual hæmoglobinuria he may die many days later from obscure
causes.
Morbid Anatomy Post-mortem the spleen is greatly enlarged, congested, and dark in colour. The
liver also is enlarged and congested, the kidneys enlarged and dark purple in colour.
Almost characteristic of the viscera in Black-water Fever is pigment of malaria, a
disease which it it be not the cause of Black-water Fever is everywhere associated
with it.
19
This then is the disease. It is necessary for us after we have summarized what
has been ascertained and surmised by other observers as to its nature to dive
our own contribution to its study.
Our researches upon Black-water Fever have been carried out in the Duars, a
district which has gained some notoriety in India as one where Black-water Fever
is prevalent. Our first step was to ascertain the conditions under which Black-
water Fever occurred and to collect such general information regarding seasonal and
local incidence, the relation to race, length of residence, and such other conditions as
seemed likely to be of importance in determining the cause and nature of the disease.
Having ascertained as far as possible the general causes bringing about Black-water
Fever there still remained for consideration the immediate mechanism concerned in
the disease process, and the question as to how that mechanism was set in action.
Lastly, there is the possibility of suggesting a rational treatment and prophylaxis
for the disease.
Three main issues therefore were before us :—
I. What are the causes bringing about Black-water Fever ?
II. What is the actual mechanism of the blood destruction ?
III. What steps can be taken to prevent the disease or to cut short its
course once it has declared itself ?
The first has hitherto chiefly engaged the attention of observers, and the state of our
knowledge at the present time has been briefly outlined.
The only attempts to explain the cause of the condition which seem at all
applicable at the present time are :
—
(a) The theory that Black-water Fever is a specific disease.
(b) That it is induced by repeated attacks of malaria, quinine occupying
a minor position as a precipitating cause.
On the other hand it is necessary to consider the possibility of its being due to
some other condition not yet indicated,
We have to decide upon the probability or improbability of each of these sug
-gestions, bringing forward if possible proof of their truth or the reverse.
But while investigating these remote or general causes we wish to approach
the subject of Black-water Fever from a new standpoint, bringing as many observa
- t i o n s a s p o s s i b l e t o b e a r u p o n t h e m e c h a n i s m o f b l o o d d e s t r u c t i o n i n t h e d i s e a s e .
Onl y on these l i nes does a true sol uti on of the di ffi cul ty surroundi ng the æti el ogy
of Black-water Fever seem possible, it is also only with a knowledge of this that we
can hope to approach the rational treatment of the condition.
PART II.
BLACK-WATER FEVER MALARIAL IN ORIGIN.
Chapter I.
BLACK-WATER FEVER CONDITIONS.
A glance at a rainfall map of India shows at once two areas where the rain
- f a l l f a r e x c e e d s t h a t o v e r t h e r e s t o f I n d i a . O n e i s a n a r r o w s t r i p a l o n g t h e
Western Ghauts and West Coast. The other is situated along the base of the
Eastern Himalayas and the Garo and Kassia Hills, where these ranges intercept
the moisture-laden monsoon currents from the Bay of Bengal ; within its limits
are included the small districts of the Darjeeling Terai, the more important
t r a c t k n o w n a s t h e D u a r s a n d t h e s t i l l m o r e i m p o r t a n t a n d e x t e n s i v e P r o v i n c e
of Assam.
It is this latter area with which, we are entirely concerned, since it will be
found to correspond to an area from which cases of Black-water Fever have
been frequently reported. In 1898 Powell (26.) records the occurrence of
Black-water Fever in Assam, reporting eleven cases which had come under
his observation in North Cachar. Shortly afterwards Seal (27) gave particu
- l a r s o f a c a s e s e e n b y h i m i n S y l h e t , a n o t h e r d i s t r i c t o f A s s a m , a n d s i x
other cases in the Darjeeling Terai. In 1900 the Rev. G. M. Crozier, M.D. (51),
described two other cases from Cachar ; and a little later Stephens and Christo
-phers noted in their report to the Royal Society that the disease was frequent in
the Duars, and also referred to a letter received by them from an Assam planter
mentioning that it had been recognised for a number of years in Nowgong.
Since then the Duars has gained a notoriety far above Assam as a Black.
water Fever country. But cases have come under the personal observation of
one of us in the Darrang district (Assam), while particulars of others have been
sent to us from various parts of the Province.
To what conditions does the district under discussion owe the occurrence
of Black-water Fever ; and why is the Duars especially the seat of the disease ?
OPENING UP OF THE SOIL.
The belief that severe malaria is often the result of opening up the soil has
long been held. To explain this, it has been customary to note that pools are
generally formed suitable for anopheles to breed in, and that malaria is the
( 21 )
227 H. D.
22
result ; yet in reality this is quite an inadequate conception of the true state of
affairs. We have been fortunate enough to see in several parts of the Tropics
operations involving " Opening up of the soil." Such operations always involve
certain conditions. The most important is the formation of enormous camps of
coolie labourers and their families, drawn from far and wide throughout the
district, or even from distant countries. In such camps of far more importance
than mere extra facilities for breeding of anopheles are certain conditions : the
mixture of races and classes involving admixture of susceptibles with the infect
-ed; the depressing effects of hardship, especially affecting the weaker, who in turn
by becoming malarial disseminators take their part in the vicious cycle ; crowding
of the population into communities larger than occur in ordinary rural conditions
and not large enough to derive the benefits to be got from the urban ; and many
other factors we need not specify. Suffice it is to say that camp conditions play
into the hand of malaria more than any others known to us ; so that in these
huge labour camps we find malaria in its intensest and most pernicious form.
Naturally the Europeans and others employed in supervision suffer in the
general trouble, since in their ignorance they dwell not apart from but in the midst
of the natives. The belief that malaria comes from the opening up of the soil
is therefore based upon fact ; but it is not the miasmatic exhalations or even the
extra facilities for the breeding of anopheles, though this too helps in the general
v i c i o u s c y c l e , t h a t i s r e s p o n s i b l e . I t s o r i g i n i s b o u n d u p i n t h e g e n e r a l c o n d i t i o n s
inseparable from the existence of great labour camps in the Tropics. To em
- p h a s i z e t h e c o n d i t i o n , w h i c h i s a v e r y r e a l o n e , w e m a y c a l l i t t h e f a c t o r " o f
Tropical Industrial Aggregation. "
Much of the area we are discussing has only been opened up and occupied
within the last fifty years and vast tracts are still jungle or virgin forest. It
owes its recent importance mainly to the tea industry, of which it is the chief
site ; and our interest in the district centres in the conditions on the tea gardens,
of which alone we have the knowledge necessary to enable us to speak.
When we come to discuss the incidence of malaria among tea-garden popula
-tions, we find that there are several points relating to the character of such popu
- l a t i o n s w h i c h r e q u i r e c o n s i d e r a t i o n . T h e i n t r o d u c t i o n a n d g r a d u a l d e v e l o p m e n t
of the tea industry has resulted in the necessity of employing large working popu
- l a t i o n s ; a n d t h e d i f f i c u l t i e s , e n c o u n t e r e d i n o b t a i n i n g a s u p p l y o f l a b o u r f r o m a m o n g
the indigenous local population has led to the introduction of vast numbers of
immigrants from various parts of India.
Fortunately for Assam immigration in this province has gone on under
a system known as " indentured labour " which regulates to some slight degree
23
conditions of life and period of residence. This system results in an immigrant
population it is true ; but one with a tendency to become more or less perma
- n e n t .
The degree of permanency, however, varies under different conditions on
different gardens and is closely bound up with the malarial intensity, the two
factors forming a vicious cycle. Certain gardens are situated upon grants
which are comparatively low-lying and include land suitable for rice cultivation ;
as a result there is more inducement for the labourer to become permanently
settled either on the garden or in the villages which spring up around it. The
fixed character of such populations and their tendency to become spread over
a wider area than that allowed by ordinary garden lines, and the fact that the
number of labourers being usually more than is required for the garden work
allows greater individual freedom and entails less arduous work, are all
factors tending to improve the general condition of the population and
lower the incidence of malaria among them. In these gardens malaria,
although present to some extent among the young children, appears to affect
the adult population but little ; and those Europeans living on such gardens
usually suffer comparatively little from the disease. It is due to preponderance
of gardens of this nature that Assam as a whole is looked upon by Europeans
as fairly healthy.
But in other gardens the yearly influx of new coolies maintains the condi
- t i o n o f a t e m p o r a r y l a b o u r c a m p y e a r a f t e r y e a r . O w i n g t o t h e v i c i o u s c y c l e s
thus introduced the population is invariably of a more shifting nature, the tend
- e n c y t o g r a v i t a t i o n o f i t s m e m b e r s t o m o r e h e a l t h y l o c a l i t i e s b e i n g m o r e m a r k e d ,
the mortality higher, and the consequent introduction of new immigrants pro
- p o r t i o n a t e l y m o r e f r e q u e n t a n d i n g r e a t e r n u m b e r .
In Assam, gardens under this category are almost invariably situated near
the foot of the hills, such a situation in Assam being therefore generally associated
with intense malaria.
If we ascertain the districts from which Black-water Fever has been reported,
we shall find that cases have almost all originated in gardens so situated.
Classified according to locality the cases of which we have the necessary
particulars are:—
North Cachar
.. 11 cases (Powell)
.. Gardens near the foot of the
north Cachar Hills.
Budderpore
. .
.. 1 case
.. Railway servant working on
hill section.
Kumbhier
. .
.. 1 case..
.. Foot of north Cachar Hills.
24
Sylhet
. .
.. 3 cases
. . .. One on a garden below Jaintia
Hills ; one on a garden near
Lushai Hills ; and one recur-
rence of a Duars case in a
healthy district.
Bishnath
..
.. 1 case
. .
.. On a garden near the foot of
the Himalayas.
Tezpur
. .
.. 13 cases
. . .. All on gardens near the foot of
the Himalayas.
North Lakhimpur
.. 3 cases
..
.. All on gardens near the foot of
the Himalayas.
Lakhimpur
..
.. 7 cases
. . .. On places known to be intensely
malarious.
Jorhat
..
.. 1 case
...
.. On a garden near the Naga Hills.
Nowgong
..
.. 5 cases
..
.. On gardens under the Mikhir
Hills.
Garo Hill
. . . . 3 cases
. .
. . Elevation unknown.
But from the many gardens situated on the plains of Sibsaugor and Lakhim
- p u r o r o t h e r p l a c e c o m p a r a t i v e l y h e a l t h y a s r e g a r d s m a l a r i a n o t a s i n g l e
case has been recorded.
In the Duars we find a system known as " voluntary labour," a system which
entails a great influx and efflux of labour far beyond that in the worst gardens
on the " indentured labour " system. So marked is the shifting character of
the population under these conditions that we have the unique phenomenon of
the whole population of a district living under conditions which resemble those
seen on any large engineering undertaking in the tropics and involved in
the general scheme are the Europeans and babus, who form the subject of our
present investigation, since it is they who, whatever one believes to be the
reason, demonstrate these conditions of industrial aggregation by the occurrence
of Black-water Fever amongst them.
As it is in the Duars that Black-water Fever is most prevalent, this
district will serve us best for the closer study of the conditions under which Black-
water Fever occurs.
THE DUARS.
The district known as the Duars lies along the foot of the Eastern Himalayas
between Nepaul and Assam. To the west, and for all practical purposes a mere
extension of the Duars, is the Darjeeling Terai.
The rainfall in the Duars is very heavy, averaging about one hundred and
f i f t y i n c h e s i n t h e y e a r , a n d t h i s , t o g e t h e r w i t h t h e c o n f i g u r a t i o n o f t h e l a n d ,
which abuts immediately upon the foot of the mountains, is very favourable
25
to the spread of malaria. When first taken over by the British about thirty
years ago, the Duars was mainly unbroken, forest ; it owes its recent importance
entirely to the tea industry, in connection with which there are in the district some
250 Europeans, a somewhat greater number of babus, and an immigrant popula
- t i o n o f a b o u t 1 5 0 , 0 0 0 c o o l i e s . T h e l a b o u r t h r o u g h o u t t h e D u a r s i s o b t a i n e d u n d e r
the " voluntary system," a system entailing, as we have seen, a more unsettled.,
population and a more constant influx of immigrants into the district than the
contract system; and the constant movements of the population and the contin
- u a l i n f l u x o f n e w - c o m e r s h a s l e d i n t h e D u a r s t o s u c h w i d e s p r e a d p r e v a l e n c e o f
malaria as probably does not exist over a like area anywhere else in India.
The most obvious features in the Duars is then the prevalence and intensity
of malaria infection. .We shall, therefore, pass briefly in review conditions in res
- p e c t t o t h i s d i s e a s e , a n d l a t e r s e e i f t h e r e a r e a n y o t h e r c o n d i t i o n s l i k e l y t o b e t h e
cause of Black-water Fever.
An idea of the universal prevalence of malarial infection may be gathered
from the following list of garden lines showing the endemic index :—
Gardens.
Race.
Month.
Number of
chi l dren.
Spl een
rate. Parasi te
rate.
Dam Di m Di stri ct.
Per cent. Per cent.
a
El l enbari
. .
Pahari as .. September
. .
20
. 95
75
b Madeshi s .. September
. .
46
80
87
Washabari
. . . . October .. . .
50
78
60
Bagracote
. .
. .
. . . . September . .
68
67
72
Phulbari
. .
. .
. . . . August .. . .
66
92
62
Pathai ora
.. ..
. . . . October .. . .
40
78
65
Manabari
. .
. . . . October .. . .
30
90
83
Ranacherra
. .
. .
. . . . .
October .. . . 100
89
82
Rungamutty ..
. .
. . . . August .. ..
69
90
58
Meen Gl as
. .
. .
. . . . August .. ..
27
93
78
Bungal ow l i nes .. ..
Factory l i nes ..
. .
. . . . August . . . .
33
91
91
Butabari
. .
. .
. . . . August .. . .
28
96
75
Dewars l i nes
. .
. . . . August .. . .
25
92
9 6
Narkati ..
. .
. .
. . . . October .. . .
50
84
96
227 H. D,
26
Gardens.
Race.
Mo n t h .
Numbr
of
children.
Spleen
rate.
Parasite
rate.
Per cent. Per cent.
Low-lying gardens.
Bullabari
..
..
. . . . October ..
. .
104
89
86
Moneys Hope
..
..
. . . . August ..
. .
26
92
85
Sissibari
.
.
. .
..
....
September
. .
40
93
90
Hati-jungle
..
. .
Barons ..
..
..
....
October ..
. .
44
89
98
Hazodcherra
. .
..
Jamadars
..
..
. . . .
October ..
. .
50
90
94
North Grant
..
.. Coles and Santals October ..
. .
28
82
93
Hyapathia
..
. .
. . . .
January ..
. .
25
96
88
Chelsa District.
Chalouni
..
a
Paharias ..
August ..
..
25
72
52
b Chota Nag-
puries
August ..
. .
25
72
52
Santals
. . . .
25
. .
. .
Sam Sing,
..
. .
. . . . December
. .
40
55
35
K i l c o t
..
..
. .
. . . . December
. .
44
95
83
Indong ..
..
. .
....
February.. ..
..
16
87
87
Nagrakata District.
Luksan ..
..
..
. . . .August
..
. .
17
99
82
Dinatorsa District.
Biniguri ..
..
. .
. . . .
November
. .
53
. .
70
Huntapara
..
. .
. . . .
April
..
. .
33
. .
70
Lankapara
..
. .
. . . . April
..
..
. .
50
20
Dulsingpara
..
..
. . . .
May
..
. .
. .
75
60
Low-lying gardens.
Huldabari
..
. .
. . . . November
. .
34
85
94
Telepara
..
. .
. . . . November
. .
112
95
89
Gayakuta
..
. .
. . . .November
. .
96
93
85
27
Gardens.
Race.
Month
Number of
chi l dren
c
Spl een
rate. Parasi te
rate.
Low-l yi ng gardens.—contd.
per cent. per cent.
Hi ndupara • • • •
. . . . November
• •
25
100
9 5
Gundapara
. .
• •
. . . . November
.. 108
83
73
Lakhubari
..
. . . . . November
34
91
94, .
Torsa District
Jai gon .. • • • •
. . . . May ..
40
75
6 0
Jal pai gur i Town
. . . .September
• •
20
40
. 25
Nayabusti
• . • •
September
• •
36
61
36
The rains which are very heavy fall from May or June to the end of September.
For several months after the rains there are everywhere small trickling streams
fed by springs and these swarm with the larvæ ofM. listoniand some other
species. By January most of the streams have become dry, and from this
time onwards to April or May extremely few breeding places exist except
on certain low-lying gardens where the springs are perennial. Anopheles adults
are notably scarce after January, except in these latter situations, and during the
months of February, March, and April they are rarely seen in bungalows ; they are
also extremely difficult to detect in the coolie houses. During this time, that is, from
January to May, fever among Europeans is at its minimum ; servants also complain
very little of fever ; and an examination of children's blood shows scantier
infections than one finds later in the year , though the actual percentage of
children infected remains much the same.
Very early in the rains malaria becomes more prominent than it has been
: servants continually absent themselves on this account ; and Europeans begin
to suffer severely. In August, September, and October malarial conditions
are at their height, but undergo some slight diminution as the colder weather
approaches, though up to January anopheles can be found without difficulty and
cases of fever are frequent.
What applies -to variations of malaria from effect of the season is equally
applicable to locality. While on almost all gardens the endemic index
is approximately 100 per cent. there are some where the conditions favouring the
spread of malaria are much greater than others, so that Europeans and babus
are more subjected to infection and 'coolies themselves suffer more from malaria.
The most noticeably malarious gardens are those so situated that throughout