NationalLibraryOfScotland/medical-history-of-british-india huggingface dataset:
39
B Before deducing the relative liability of persons on these different gardens
to attack, it is necessary to consider in each case the number of residents concerned
and also to separate from among the number of attacks those belonging to
Europeans and babus, respectively.
The number of Europeans on a garden in any given year varies very little, and
we give the number known to us at the present time, which may be taken to
represent fairly accurately the numbers exposed to Black-water Fever on those
particular gardens. The cases among Europeans probably represent the actual
incidence more or less accurately; among the babus, as we have remarked before,
the number of cases reported is probably only a portion of those actually occurring,
and this can only be relied upon. as a very rough indication of the incidence for
1898—1907. The figures for 1907-08, on the other hand, include most, if not all,
the cases that have occurred, and give a much more accurate indication of places
where babus are most liable to attack.
The gardens thus prominently brought forward are :—
Neora Noddy.—This garden is situated further south than any of the gardens
of the Dam Dim district, Being a lower-level garden it is correspondingly more
waterlogged. It is situated amongst a number of old beds formed by the con-
stantly changing courses of the Chel and the Neora rivers, at the junction of which
the garden is situated, and in the months of February, March and April, when
the gardens nearer the hills are practically devoid of Rater, many pools still exist
at Neora Nuddy, One European lives at the garden, which is comparatively
small. In all cases the Europeans have suffered very severely from malaria, so
that the garden has an extremely bad reputation,
Barons.—This garden is one of three or four, including Bullabari, Sissibari,
Kumli, Glencoe and Hahiapathia situated just where the drainage from the
higher land issues in a line of springs and gives rise to innumerable trickling
streams and to swamps, many of which contain water throughout the whole
year. The streams which swarm with larvæ of M. Listoni are so numerous that it
is scarcely possible to walk more than one hundred yards without crossing one
of them.
The assistants' bungalow, where most of the European cases have occurred,
is surrounded on three sides by a deep hollow containing a small stream, which
only disappears for a month or two at the end of the dry season. Within one
hundred yards is a larger stream running throughout the year. This stream
contains much vegetation, and anopheles larvæ swarm in it. At a slightly greater
distance is a small swamp, Within one hundred yards of the bungalow are
40
extensive coolie lines. In no other bungalow in the Dam Dim or Chelsa districts
are the conditions that favour malaria so striking and pronounced.
Bullabari.—Adjoins Barons: but is on a slightly higher level though almost
as intensely malarious.
Sissibari.—Also adjoins Barons; and is under somewhat similar conditions
as regards malaria.
Meen Glas—Is a garden at the immediate foot of the hills, adjoining uncleared
forest. In the dry season there is practically no water except that obtained from
deep wells, but in the rains it is crossed by numerous small shallow Streams, which
remain running until December or thereabouts.
Both the manager's and the assistants' bungalows are very badly situated
as regards malaria, the latter being within a short distance of one of the streams
mentioned above.
The following was the result of the examination of the blood of those living
in the servants' quarters at the assistants' bungalow in August:—
Spleen.
Parasites.
1. Child, 3 years
...
... Spleen
.. Benign Tertian Rings.
2. „ 5 months
..
. .
„
..
Benign and Malignant Tertian
mixed.
3. Woman, 22 years
..
„ .. Nil.
4.
,,
20 „
..
. .
Nil
..
Nil.
5. Boy, 10 months
..
.. Spleen .. Benign Tertian Rings and
Gametes.
6. Woman, 25 years
..
.... Nil
..
Nil.
7. „
20 „
..
.. Spleen
..Malignant Tertian Parasites.
8. Child, 1 year
..
. .
„
.. Crescents, also Benign and
Malignant Tertian Rings.
9. Woman, 20 years
..
.. Nil
.. Benign Tertian Parasites.
10. Sweeper, 25 „
..
. . Nil
..
Nil.
11. Cook, 35 ”
..
.. Very large
spleen.
Nil
.
12. Mesalchi, 25
„ . . Very large
spleen
Nil.
.
13. Child, 18 months
..
.. Spleen
.. Benign Tertian Rings and
large forms.
41
14. Girl, 4 years
Spleon
...
Nil.
15. Woman, 25 year
.. .. Nil
..
Nil.
16.
,,
25 years
..
.. Nil
Nil.
17. Girl, 3 years
..
.. Nil
..
Quartan Parasites.
18. Woman, 28 years
.. ..
Nil
..
Nil.
19.
„
50
„
. .
Spleen
..
Benign Tertian Parasites
20. Bearer, No. 1,30 years
..
.. Nil
..
Nil.
21. Bearer, No. 2, 28 „
..
.. Spleen
..
Nil.
22. Syce, 35 years
Nil
..
Nil
23. „ 30 „
..
.. Nil
..
Nil.
24. Grass-cutter, 14 years
..
.. Spleen
..
Nil.
25.
,,
20 „
..
.. Spleen
. .
Nil.
In this case all the actual bungalow servants (male adults) were getting 10
grains quinine once a week; but none of the women or children were doing so.
One of the two European residents in this bungalow had Malignant Tertian
infection with Crescents.
Baradighi .—Occupies the position in the Chelsa district that Necra buddy
does in the Dam Dim district, being a good deal further away from the hills, and
at a lower level, than any other garden in the district. It is situated close to
various old beds cf the Neora river, and is cut up by swampy hollows and flowing
streams. Everywhere there is tall jungle and dense swampy growth, the general
effect being more like conditions in tropical Africa than any other place we have
seen in India.
Two of our cases occurred in the babus houses, which are situated elcse to-
gether; one in the bunya's shop; and one in the tea-house lines: all of which places
are within a hundred yards of each other. A fifth case, which we were unable to
see, has since occurred. We first visited this garden in December getting word
of two cases which had occurred. almost simultaneously. On reaching the garden,
we found a third babu, who had been in the garden only a fortnight, down with an.
ordinary attack of simple tertian; in the bunya's shop, where the third case later
occurred, we found two out of three of the shopkeepers with parasites in their
blood; it being one of these two who was subsequently attacked with Black-water
Fever.
Without exception, the gardens on which Black-water Fever is more tha
usually frequent are those which one would point out as the most malarious.
227 II. D.
L
42
EFFECT OF RESIDENCE.
Of the 160 cases recorded by us, in which we have the necessary information,
there is only one which may have occurred under six months' residence, this was
in a Bengali child, who contracted Black-water Fever after about three months'
residence at Barons, under conditions of the most intense malaria. In Europeans
there have been no cases under six months' resident, and considering first attacks
in Europeans, where exact data is available, we get the following results:—
Attacks.
Under 6 months
. .
..
. . . .
0
Between 6 and 12 months ..
..
..
. .
8
,,
12 ,,24
„
. .
. .
..
..
40
,,
24 ,, 36
„
. .
. .
. .
12
„
36 „ 48
„
..
..
..
. .
5
,,
48 „ 60
„
. .
..
. .
. .
1
Examining in detail the cases on the 4th and 5th year, we find that, in both
cases, the man had been for a period of about two years under new conditions;
as for example :—
Case no. 4.—One year at Narkati
Two years at Rangamutee
Both as regards Europeans compa-
ratively healthy gardens.
Then went to Barons, and was attacked two years after going there.
The same tendency to bring residence under Black-water Fever conditions
to about two years is noticeable even in those cases in, the .3rd year.
Case no . 5.—Kumlai,
hen to Barons where he was attacked 18 months later.
In regard to the occurrence of attacks after five years' residence we have in
Euroneans:—
Cases which have occurred during the first five years
..
..
24
Cases Which have occurred at some later date
..
..
5
Of these five cases at later dates, we find that two had been home and cal
out eighty months and two years respectively before attack: the history of one of
the other cases is characteristic.
43
Case no. 51.—Had been out 10 years. Went to Neora Nuddy in December
1901. Went home and. came out end of 1902. Stayed at Neora Nuddy and had
fever. 1905 went to Sungachi (Sungachi bungalow is very well situated as
regards malaria) and there had the healthiest year he had had in the district. In
1906 went to Neora Nuddy and suffered badly from fever; he describes it as the
worst time he had in the Duars with attacks of fever repeated at shorter and
shorter intervals until Black-water Fever intervened.
In babus the same tendency for first attacks to occur after about 18 months
or two years' residence is noticeable; but a large number of cases occur in babus
who have been many years in the country. The reason for this is not very clear;
it is possible that closer acquaintance with the conditions which influence this
community might throw light on the matter. In many cases we have noted a
special period of infection preceding attacks, suggesting that for some reason
the conditions under which a babu had been living had become changed (vide
case XI).
After the first attack there seems a tendency for further attacks to occur
within a few months. Whether this is due merely to a continuance of the con-
dition or argues an induced greater susceptibility is uncertain. A summary of
the periods at which second attacks occurred in our cases shows that there is
the greatest liability during the first year, and especially the first six months,
after an initial attack:—
1st month
..
..
.. .. .. ..
0
2nd ,,
.. .. ..
. .
. .
. .
1
3rd ,,
.. .. .. .. .. ..
..
2
4th ,,
.. .. .. .. .. ..
..
4
5th ,,
.. .. ..
. .
..
..
..
1
Between 6th month and end of 1st year
.. .. .. ..
4
Between 1st and 2nd year
.. .. ..
. .
. .
2
Over 2nd year ..
.. .. .. .. .. ..
3
Third attacks are in the Duars much less frequent than second attacks.
That residence for a certain time under special conditions is necessary before
Black-water Fever can be contracted, and that after several years there is a
greatly reduced likelihood of attack, cannot we shall see later be explained as
being due to mere accidential circumstances; and, if we decide that this relation
to length of residence is bound up with the essential nature of Black-water Fever
its recognition must profoundly modify our conception of this disease.
44
COOLIE ANÆMIA.
An. extremely interesting condition is we think worth recording. Planters
in Assam have long recognised that a large proportion of new coolies, especially
at the end of their first season, and during the whole of their second and
sometimes their third year, are particularly liable to suffer from anæmia of the
severest type. This tendency is most marked among certain classes notably North-
Westers, Central Province coolies, Ganjamis, and people from the plains of Bengal;
coolies from Chota Nagpur, the Santhal Pagannas, and the hill tracts of Madras
do not suffer so frequently. The period from the second to the third season is
extremely fatal for new arrivals, but once this dangerous time is passed and
recovery from anæmia has taken place, acclimatization becomes more or less com-
plete, and by the end of the fourth year a coolie is far less liable to suffer from
sickness than he was on first arrival. A similar condition may be recognis-
ed among coolies coming to the Duars. There is not the least doubt that this
condition is due almost entirely to malaria, and the length of the period required
for immunisation is very significant in, relation to what we have noted of the
occurrence of Black-water Fever in Europeans.
SPECIAL SUSCEPTIBITILY AND FAVOURING CONDITIONS,
It is our experience that those who have suffered more than usual from
malaria in a Black-water Fever country fall victims in a proportionately short
period to Black-water Fever.
The following are the cases in Dr. Brown's records in which attacks of
Black-water Fever occurred one year or under from first arrival. A perusal of
the cases in the complete list (vide appendix) will show that Dr. Brown has
especially picked these people out as suffering more severely than usual from
malaria :
—
Case 7—Mr. T,—Came out from home to Barons. After first few weeks
suffered from repeated and severe malaria. Had Black-water Fever
eight months after arrival.
Case, 24—Mrs. G. —Suffered very badly from malaria, and was unable
or unwilling to take quinine on account of pregnancy. Had Black-
water Fever six months after arrival.
Case 58—Mr. T. (Padre). —Notoriously exposed himself to infection in
the discharge of his duties, and suffered more than usual from CO
m
-
stant attacks of fever. Had Black-water Fever one year after arrival.
Case 9 —Bab S. —Came with his wife and daughter, aged 8 years, to live at
Barons, North Grant, in the midst of coolie lines situated in the most
45
malarious conditions of which it is possible to conceive. A few months
after arrival (September) the daughter was attacked with Black-water
Fever, but recovered. In February following, 9 months after arrival,
the wife was attacked with Black-water Fever and died. In, June,
a year after arrival, the babu was attacked, but recovered. In, Dec-
ember the daughter was again, attacked and died.
Case 49—Mr. P.—A Frenchman, from Pondicherry. Lived at Neora
Nuddy and suffered a great deal from fever. Was attacked with
Black-water Fever after eight months.
The same association, with malaria also applies to questions of change of
residence, of season, and of locality, to the existence of Black-water Fever houses,
an,d the special susceptibility of relations, an,d of persons livin,g in, the same place,
to incur attacks of Black-water Fever ; for such cases seem always most simply
explained by the amount of malarial infection, that has been, experienced.
Whatever explanation, be given it still remains a significant fact that, n,ot
only is the general distribution of Black-water Fever and malaria in India close-
ly related, but the in,vestigation, in, detail of such a district as the Duars shows
that Black-water Fever is most frequent on the most malarious gardens, and in,
the most malarious seasons; also that it tends to occur early an,d to be severe
in the case of those who have been especially subject to malaria.
The more minutely we enquire into conditions we find therefore n,ot discre-
pancies, but an, even closes relation, between, the incidence of Black-water Fever
and the intensity of malaria; and this is so marked that on,e is forced to believe
that, even, if the diseases possess a different origin, they must none the less be
dependent on almost similar conditions for their propagation.
That any circumstances of a general nature are likely to be concerned in the
causation of Black-water Fever we have seen to be improbable; and we are left
therefore with the alternative hypotheses:—
(1) That Black-water Fever is due to a specific organism.
(2) That it is of malarial origin.
47
CHAPTER III.
BLACK-WATER FEVER NOT DUE TO A SPECIAL PARASITE.
INFECTIVITY OF BLACK-WATER FEVER.—There is nothing in the general
clinical picture of Black-water Fever to suggest that it is an infectious dis-
ease, such as Yellow Fever, or Sprillosis; epidemics have, it is true, been, described,
but with a want of accurate and detailed observation, which renders it impos-
sible to judge whether they have been, merely the result of large numbers of per-
sons being placed simultaneously under Black-water Fever conditions, or due
to the spread of infection.
If malaria will produce Black-water Fever in fifty per cent. of the new-
comers in, a small community, there is no reason why in, the case of a large num-
ber of susceptible persons brought more or less simultaneously under Black-water
Fever conditions, there should not result a large number of cases simulating
an epidemic. To quote, without particulars, epidemics of the disease on,
railways or in, armies has therefore little bearing upon, the question.
In, the Duars attacks occur quite independently of one another in widely
separated gardens and districts. The incidence, as we have pointed out, shows
a frequency directly relative to that of malaria; and we have seen, that attacks
are more frequent in, certain, bungalows, in which there is especial danger of con-
tracting the disease. In such bungalows attacks occur generally at long and
irregular intervals; but in regard to length of residence of those attacked they
conform to the general rule.
HISTORIES.
Neora Nuddy.—A bungalow with rarely more than one European.
P. attack September 1897, after 8 months' residence.
L. attacked October 1905, after 7 months' residence; second attack in December
1905.
S. attacked January 1907, after one year's residence.
Note.—The early onset of the disease under especially intense malarial conditions.
Barons.—
(a) Assistants' bungalow. Two men resident.
Mr. C., attacked May 1889
... second attack September 1889.
.. 2 years' resident.
Mr. McL., attacked August 1890
. . 2 ,,
, ,
Mr. E., attacked October 1891
... second attack March 1892
. . 2 , ,
, ,
48
Mr. D., attacked October 1899 ..
second attack February 1901.
. .
.. 2 years' resident.
Mr. G., attacked May 1901
..
.. .. 18 months' , ,
(b) Babu's house at North Grant lines. A single babu and his family only resident.
Daughter, aged 8 years, attacked September 1903
3 months' resident.
Wife attacked February 1904 ..
8 ,,
, ,
Babu attacked June 1904 ..
..
.. 1 year's
„
Daughter, second attack, December 1904.
Note the sequence of child, woman, and man in the order of their susceptibility to
malaria (vide page 44) and early onset under extremely intense malarious conditions.
Bullabari.—
(a) Assistants' bungalow: Two men resident.
Mr. S., attacked January 1897 ..
..
.. 2 years' resident.
Mr. S., attacked February 1904 ..
..
..
second attack January 1906.
2 „
, ,
(b) Manager's bungalow (very close to last).
Mrs. G., attacked July 1896
..
...
6 months' resident.
Mr. G., attacked January 1904 ..
..
.. Several years at bungalow, but
returned from England two
years before attack.
Sissibari.—
Assistant's bungalow: One man resident.
Mr. T., attacked January 1889 ..
..
.. Unknown.
Mr. W., attacked October 1901
..
.. 2 years' resident.
Mr. F., attacked September 1906
.. ..
second attack December 1906.
18 months' „
The theory that one is dealing with accumulating chances of infection is
scarcely a satisfactory explanation of such a state of affairs, for the infection if
it exists is evidently most localised in, the very houses where these people are
living and it is inconceivable that, in spite of this, a new-comer should never, by
any chance, be attacked.
And the conditions which we have just described are characteristic of Black-
water Fever everywhere: in tropical Africa we have seen, more than, 50 per cent.
49
of men who went to live at certain bungalows go down eventually with Black-water
Fever ; but in every case the peculiar feature of a certain length of residence was
preserved.
What usually happens, when a new-corner comes to a house in which there has
been much Black-water Fever, is that he very promptly contracts not Black-water
Fever but malaria. Of this we have seen repeated examples.
Dr. Emlyn Jones (52) refers to a case where a nurse, who came from Calcutta
to the Duars to nurse a Black-water Fever patient, was stated to have contract-
ed Black-water Fever ten days later. On making enquiries of Dr. Brown, he in
- f o r m e d u s t h a t t h e n u r s e c a m e t o t h e D u a r s t o a t t e n d a c a s e o f B l a c k - w a t e r F e v e r
which was fatal in about ten days ; almost immediately after her return to Cal
-cutta she had merely a severe attack of ordinary malaria.*
A new-comer who came from England direct to Barons in November
1907 contracted, not Black-water Fever, but severe malaria within ten days.
Another person who came from Europe about the same time was attacked with
- i n t h e f i r s t m o n t h .
It is difficult to believe that Black-water Fever is an ordinary infective dis-
ease. If infective it must be present in some latent form ; and like malaria this
must be endemic.
POSSIBLE ORGANISMS CONCERNED.—The special organism that would at first
thought appear most probable as the cause of Black-water Fever is some form of
piroplasma, since this is the only kind of parasite we know producing such symp
- t o m s .
Of piroplasms there are two groups broadly distinguishable :
(a ) The large typical forms P. Canis, P. Bigeminum, and P. Ovis ; and the
irregular forms, more or less minute, lately classed in a new genus Theileria.
Hæmoglobinuria, in so far as it has been recorded, is confined to the first group.
It occurs in the dog (Malignant Jaundice), the ox (Red-water), and the sheep
(Carceag).
I n t h e o x a n d d o g h æmo g l o b i n u r i a i s a s s o c i a t e d wi t h a l a r g e n u mb e r o f
parasites in the peripheral blood and in, the organs. In, infection with P . e q u i
parasites are also present in, large numbers. In our own experience, among dogs
h æ m o g l o b i n u r i a n e v e r o c c u r s e x c e p t i n c o n n e c t i o n w i t h i n f e c t i o n s w h i c h i t w o u l d
be impossible for any competent observer to overlook.
* Note.—Thi s was ascertai ned by personal enqui ry.
227 H. D. N
50
East Coast Fever, a disease due to infection with P. parvum, one of the minute
forms of piroplasma is characterised by visceral lesions of a marked kind ; but
h æ m o g l o b i n u r i a i s n o t a s y m p t o m : a n d e v e n , t h e m i n u t e s t f o r m s o f p i r o p l a s m a ,
though their demonstration may require some care in, the preparation, of speci-
mens, are, if present, at once evident to critical examination.
Heart-water in, sheep has been shown, by Lounsbury (53) to be transmitted
by ticks (Amblyomma); and it has on, this account been, suspected to be a piro
-plasmosis due to an, ultra-microscopic parasite. But here again hæmoglobinu
ria is n,ot a symptom ; and we have too insufficient a knowledge of the disease
to base conclusions on, the above mentioned view of its nature.
Judging from analogy, we should expect, if Black-water Fever were a
piroplasmosis, to find parasites without difficulty in the peripheral blood and
organs.
Some other parasites (Relapsing Fever, Yellow Fever, etc.), however, give
ri se to a good deal of bl ood destructi on, and even hæmogl obi næmi a. (But v i d e
e x t r a - v a s c u l a r l y s æmi a , P a r t I I I ) ; we h a v e t h e r e f o r e t o b e a r i n mi n d .Spiro
- c h œ t œ
o r e v e n ,
B a c t e r i a
. H æ m o g l o b i n u r i a i s a l s o d e s c r i b e d i n c e r t a i n , f l u k e
infections (Dantec) (54) ; and it is now recognised that in Anchylcstomiasis
t h e a n æ s m i a m a y p o s s i b l y b e d u e t o t h e a c t i o n , o f h æ m o l y t i c b o d i e s p r o d u c e d b y
the worms : there is thus considerable scope in the possible parasitic conditions that
may give rise to Black-water Fever. But it is the analogy of the parasitic
h æ m o g l o b i n u r i a s o f a n i m a l s , w h i c h h a s c h i e f l y i n f l u e n c e d c o n c e p t i o n s o f t h e
disease ; and if such an analogy is found not to hold good, there is a greatly dimi
- n i s h e d p r o b a b i l i t y o f B l a c k - w a t e r F e v e r b e i n g a d i s e a s e o f s p e c i f i c o r i g i n , .
EXAMINATION OF THE PERIPHERAL BLOOD.
In these observations we used very carefully-made films stained by Giemsa's
s t a i n , w i t h a n d w i t h o u t t h e a d d i t i o n , o f a t r a c e o f a l k a l i , w h i c h g r e a t l y
enhances its staining power. Our lenses were Zeiss apochr. f. I. 50mm. N. A.
I. 30 with compensation eye-pieces Nos. 6 and 12.
But the most minute and exhaustive scrutiny of the red cells, the plasma
and the leucocytes of our cases has failed to give any indication, of the presence
of a piroplasma-like organism ; yet several of our cases have been seen quite early
in the course of the attack, an,d two only a few hours after the onset.
The use of neutral red in. two cases, on,e of which was a severe one with intense
h æ m o g l o b i n u r i a , h a s s h o w n c o r p u s c l e s s t a i n e d i n a c h a r a c t e r i s t i c m a n n e r ( v i d e
Spherocytes, Part III) : but the closest scrutiny showed no included parasites.