NationalLibraryOfScotland/medical-history-of-british-india huggingface dataset:
178 Report on Kála-ázar.
It is further stated that
—
"there is no material change in the country to which the
prevalence of this fever could be traced; and the most probable
cause to which it could be ascribed is climatic influences, viz.,
scantiness of rain and excessive heat, which intensified and con
-centrated the marsh poison."
That this is the true explanation is proved by the fact that
a study of the monthly rainfall and fever-rates in both
Dinajpore and Rungpore from 1881 to 1894 shows a most
definite relationship between a low rainfall, especially if it is
also irregularly distributed so as to cause alternate flooding
and drying up of the land, and an increase of the fever-rat
e. Moreover, in the years 1873, 1875, and 1877, in addition to
the rainfall being much below the average in Dinajpore and
Rungpore, in every case it was very irregularly distributed.
For instance, in the year 1873, the monthly rainfall in Rung-
pore was as follows:—In the first three months only 1·2 inches
fell, in April there were 8·24 inches, in May 1·07, in June
13·09, in July 3·93, in August 14·11, in September 2·63, and
none in October or November, and but 0·38 in December,
the total being 44·64 inches, or barely half the normal average,
which was 88·19 for the five years previous to 1873; so
that there must have been a succession of floods followed by
the exposure and drying up of the saturated soil under a May,
July, and September sun, than which no more favourable cir
-cumstances can be imagined for the multiplication and escape
into the air of the malarial organisms by their being
carried up in the evaporating moisture. When we see a series
of such years one after the other, is it any cause for wonder
that fever should become more and more prevalent and intense
until an epidemic of malarial fever is produced? Is it surpris-
ing that in this year it is recorded of the fever in Rungpore
that—
"From May to December it continued increasing in intensity, so
that the majority of the population were completely prostrated by
repeated attacks of the disease?
"
In this connection the Civil Surgeon's description of the
Origin of kála-ázar, etc.
179
physical condition of the country in the district of Rungpore,
will not be inappropriate. He writes
—
"The bheels, the ever-reeking repositories of putrefying organic
matter, had not their contents diluted or overflown into rivers, as is
the case with other years; but the thick slime from the heat got
thicker and thicker, exhaling the offensive gases in a concentrated
form" (which put into the more precise, but less picturesque, language
of modern science, might be paraphrased: exhaling the malarial
organisms in an intensified form). "The soil, too, by scanty rain and
alternation of rain and sun, had its deposite of organic matter set
into putrefaction, which, if the rains were plentiful, would have been
washed off into large bodies of water before doing harm."
To continue, in 1874, the rainfall was again very difficient
in the early part of the season, but a heavy fall took place in
September and October, which brought the total nearer to the
average than in the preceding or following years, and the
mortality from fevers was slightly less in the district of
Dinajpore. In Rungpore, however, the deaths from fever
were much greater than in 1873, the mortality in the selected
areas, which furnish the most correct figures, being
23·61 in 1874, as against 11·45 in 1873, which, allowing
for improvement in registration, still leaves a large margin
of actual increase. The fact that the seasonal incidence
of the disease extended over a much longer period than
usual, shows that it had attained to epidemic intensity
(this being, as I have shown in Section VI, characteristic
of the epidemic malaria of Assam), while the fact that
there was a marked decrease in the fever after the heavy
rain in September, illustrates still the further dependence of
the increased fever-rate on the previous low rainfall. The
following quotation will suffice to prove these two occur
-rences:
"The fever, which had commenced in May 1873, earlier than in
former years, and increased in intensity to December, reducing the
people to the lowest state of vitality from repeated attacks, and
inducing a state of spleen and liver affections, and finally, desentery
and general dropsy during the sharp cold of December and January
1874, continued to prevail up to the rainy season of the year under
2 A 2
180
Report on Kála-ázar.
report (1874). But curiously, after the heavy rains in September,
and especially after the cyclone of the 16th October, the disease
abated."
In 1875, there was a further increase of the fever-rate in
both Dinajpore and Rungpore, the mortality in the former
district having increased in the selected areas from 20·36 to
24·75, and in the latter from 23·61 to 24·56. From Dinajpore
no report was received from the Civil Surgeon for the third
year in succession, so details as to the type of the prevalent
fever cannot be given here. In Rungpore, however, it is
recorded that
—
"Remittent fevers are common and fatal in this district, but the
principal disease is intermittent fever, which is most prevalent during
and after the rains. Chronic enlargement of the spleen and liver
follows repeated attacks of the disease, and in the cold-weather months
diseases of the lungs and general dropsy supervene."
This year once more the rainfall was very much below the
average, being only 43·6 in Dinajpore, and in Rungpore was
60·45. It was also very unevenly distributed. It is worthy
of note that the six areas, which are especially mentioned
as having suffered most severely from fever during this
very unhealthy year, are all situated in the east of the
Rungpore district, that is, in the portion which borders
on the Garo Hills terai, from which it is only separated
by the Brahmaputra river, which with its numerous islands
is included in Rungpore, and, as already noted, these river
banks and islands shared in the outbreak. Now this year was
the very one in which it was ascertained by an independent
study of the Assam district reports, before I had any knowledge
of the details of the Rungpore outbreak, to have been that in
which the fatal depopulating epidemic malarial fever first made
its appearance in the south-west corner of the Garo Hills dis
-trict; and, although the fever in this terai country at the foot of
the hills might have been expected to be intensified by the same
seasonal influences, which have been just shown to have affect
-ed that in the Rungpore and Dinajpore districts, yet as a matter
of fact the rainfall in the Garo Hills was not deficient at that
Origin of kála-ázar, etc.
181
time, for the fall there for the years 1873—79 averaged 120
inches, which happens to be exactly the same figure that the
average for the years 1880—87 works out to be. Moreover, the
fever in the Garo Hills appears to have started in two separate
places, both in the direct lines of communication from Rungpore,
and not uniformly over the district, as it should have done had it
originated there owing to seasonal influences, and in this respect
it follows the same course that the epidemic of Lower Bengal
did when it invaded Bardwan. It will also have been observed
that the type of fever in Rungpore was exactly that of the
Assam epidemic, while the mention of remittent fevers as hav
-ing been common and fatal in the Rungpore district in 1875, is
worthy of note, as indicating a still further increase of the
intensity of the fever in the district during that year.
The subsequent history of the outbreak of fevers in
Dinajpore and Rungpore need only briefly be given. In 1876
the rainfall was again deficient, being only 66·55 in Dinajpore
and 65·69 in Rungpore. The fever in both districts showed
a still further increase, the mortality in the selected areas
being 32·90 and 28·15, respectively, as against 24·75 and
24·56 in 1875. In 1877, the rainfall was once more low in
Dinajpore, being only 67·27 inches, but in Rungpore it was
91·03, but was extremely unevenly distributed. There was a
further increase of the fever mortality in both districts, more
especially in Rungpore, in spite of the heavy rainfall, which
shows what an epidemic hold the fever had got on this district.
In 1878 there was an unusually heavy rainfall in Rungpore,
namely, 121·5 inches, and the fever both here and in Dinajpore
showed a slight decline. In this year it is recorded that
—
"at Rungpore the disease prevailed virulently in some places"
(just as it was at this period doing in some places in the Garo Hills
district under the name of kála-ázar), "while others enjoyed a toler
- a b l e a m o u n t o f i m m u n i t y ; b u t , o n t h e w h o l e , a l e s s e r a r e a w a s
covered by it, and the mortality had slightly declined."
In 1879, the rainfall was again above the average, and
there was a marked decline in Dinajpore of the fever-rate,
and a distinct improvement also in Rungpore.
182
Report on Kála-ázar.
We see then that in this remarkable series of years, from
1872 to 1877, there was a very deficient rainfall in five out of
the six in Dinajpore, and in four out of the first five of them
in Rungpore, and that the influence of this deficiency in
increasing the prevalence of malarial fevers, which are always
severe in these districts, was still further strengthened by the
very irregular distribution of what did fall in alternate periods
of heavy rain and prolonged intermissions, while that of the
year in which the total fall was not much below the normal,
was very deficient in the first three months of the rainy season.
An examination of the monthly rainfall of these and other
districts of Bengal for the years 1879 to 1894, inclusive, shows
nothing approaching to such a series has occurred during this
prolonged period, nor, let us hope, is likely to occur again for
many years to come. That it was accompanied by, and was
indeed the cause of, the steadily increasing prevalence and
intensity of the fever of those years, there can be no doubt,
while the absence of any such cause for the intensification of
fever at the foot of the Garo Hills at the time that kála-ázar
began in that place, together with its simultaneous outbreak at
two widely separate places, both in the direct lines of commu
-nication with Rungpore, and its exact similarity with
the type that was prevalent in Rungpore with epidemic
intensity at the time of its commencement, makes it
certain that the epidemic malarial fever of Assam arose from
an intensification of the ordinary malarial fever of Rungpore
by an extraordinary succession of abnormally unhealthy
seasons such as can fortunately very seldom recur.
THE RESEMBLANCES BETWEEN THE ASSAM EPIDEMIC
FEVER AND THE "BARDWAN FEVER".
The description already given of the spread of the epide
-mic malarial fever in Lower Bengal, usually known by the
name of the "Bardwan fever," is sufficient to show that in its
general course it is exactly similar to the epidemic fever of
Assam, known by the name of kála-ázar. That it was also
Resemblances between Assam and "Bardwan Fever". 183
similar in all its essential details, will now be briefly proved by
extracts from the Bengal Sanitary Reports of the seventies, in
which will be found the views of all the Civil Surgeons and
others who studied the disease in the affected districts, especial
attention being paid to the important points of its nature and
mode of spread.
Firstly, as to its nature, there was a practically unanimous
consensus of opinion that it was from beginning to end a mala-
rious fever, although,—as was also the case in Assam with
regard to kála-ázar,—suggestions have been made that there
was something in it in addition to malaria, pure and simple, the
chief of which is that it was a typho-malarial fever, the typhus
fever factor accounting for the infectious properties of the
disease.
Dr. Elliot, who was Civil Surgeon of Bardwan up to 1871,
and had a great experience of the disease, considered it to
be —
"an exaggerated and congestive form of malarious fever, most
frequently of the intermittent, but also of the remittent, type."
Dr. French, who succeeded Dr. Elliot in Bardwan, writes
in 1874:
"Ever since I came into the district, I maintained the opinion that
t h e ' B a r d w a n f e v e r ' w a s o n l y a n e x a g g e r a t e d o r m a l i g n a n t f o r m o f
the ordinary endemic fever of Bengal, and similar to that observed in
marshy places and other unhealthy tracts. I am further of the opinion
that the events of 1874 have set the matter beyond all doubt."
The events referred to were the nearly complete absence
of the bad type of cases, their place being taken by a milder
type and fewer remittent cases, and its seasonal distribution
had become reduced to its normal limit. Dr. Wilkie, who was
specially sent to investigate the fever in 1874, agreed with
Dr. French in considering it to be entirely malarial in its
nature. Dr. F. Barker, who saw much of the disease in
Beerbhoom, says:
"This fever is in every respect identical with malarious fevers
which prevail elsewhere. It is, however, of a more tenacious and
fatal character than I have seen in other parts of India."
184 Report on Kála-ázar.
Dr. Joubert, who was Civil Surgeon of Bardwan in 1875,
writes
—
"I am of the opinion that it was a purely malarious fever locally
intensified into a very virulent type. This type is now rarely met
with, either because the exciting cause has died out, or because the
disease has exhausted itself on all such as were liable to be affected
by it. All those who have had opportunities of studying the disease
thoroughly, hold the same opinion that it was purely a malarial
fever."
The disease also followed the seasonal mortality curve of
the ordinary malarial fever in the same district. Thus writing
on this point, Dr. Wilkie says
—
"Now the year 1872 was a genuine jor-bekar year; keeping
that fact in view, the similarity of the mortality curves in the three
years in all respects, except that of height, seems to me a very
significant fact with respect to the question of the nature of the
disease."
The way in which in any place it began insidiously and
became worst after a year or two, was also a characteristic
feature of the epidemic in Bardwan. Thus, Dr. Jackson, the
Sanitary Commissioner for Bengal, who spent part of two
years in the affected districts studying the disease, and whose
voluminous and invaluable report will be frequently quoted
from, writes on this point
—
"It is to be remembered that in all these areas successively attacked
the year of invasion is never the year of intensity. The fever is
generally present for a year without attracting much notice. As a
rule, the year of greatest intensity in villages is the third year,
in towns the second year, is not unfrequently the worst."
The tendency of the fever to relapse again and again
until all the signs of extreme malarial cachexia supervened,
was also frequently mentioned in the descriptions of the
disease. Thus it is recorded:—
"In some severe cases fever was prolonged for ten days or a
fortnight, and the prostration of strength was excessive. The
patients were reduced to skeletons; recovering gradually in two or
three months, subject, however, to relapses, which, as a rule, in
-variably followed. The fever, however, in these cases of relapses
Resemblances between Assam and "Bardwan Fever" . 185
does not last long, yet the patients become weaker and weaker, and
ultimately enlargement of the spleen, liver, anæmia, and dropsy set
in."
The type, however, of the Bardwan cases differs in some
important points from that of the Assam epidemic, as would
naturally be expected, seeing that the two epidemics had
their origins in such widely separated places as Jessore and
Rungpore. Thus, the Bardwan fever cases seem to have
been of a more acute nature, and to have been frequently
rapidly fatal with cerebral symptoms. Again, a larger number
of persons in one house or village seems to have suffered from
the fever at the same time in the Bardwan epidemic. The
severe remittent fever, which was always preceded by an
increase of ordinary fever, is described by Dr. Jackson as
follows:—
"From the first the patient had a stupid drowsy, brain-poisoned
aspect; was unwilling to talk or answer questions; the intellect
gradually became more and more confused; and he lost the power of
understanding what was said to him, and it was only by shouting
that he could be roused at all. From the first also there was intense
prostration and loss of muscular power. In the cases which proved
fatal, the stupor passed rapidly into coma, and after 12 to 36 hours of
utter insensibility, death occurred. Some of these cases proved
fatal in three days; others lasted a week or ten days."
It was these cases that made Dr. Jackson believe the
disease to be "typho-malarial fever," but it is worthy of note
that they formed only a small proportion of the cases, and
Dr. French, in writing about them, says:
"This condition, if not immediately relieved by large doses of
quinine, passes into a state of coma with dilated pupils, etc., and
then death."
Which implies that if large doses of quinine are given,
they may recover. The Bardwan fever was then a very
intense form of malarial fever, just as so-called kála-ázar is,
but the type of fever differs in the two cases, just as malarial
fevers differ from one another all over the world. Let us
see now how it spread.
2 B
186
Report on Kála-ázar.
As the appointment of Sanitary Commissioner of Bengal
was only made in 1868, when the first sanitary report
appeared, very few details are on record with regard to
the earlier course of the Lower Bengal epidemic fever in
Jessore and Nuddea, but ample material is available as to its
subsequent spread in Bardwan, Beerbhoom, Midnapur, and
Hooghly. Although it was patent to all that the fever invaded
Bardwan from the east, or Nuddea side, yet so firm was the
conviction that the fever was a malarious one, and ipso facto
could not possibly be communicable in any way whatever;
that numerous theories were started one alter the other to
account for the spread of the fever on local grounds, as each,
in turn, was rendered untenable by the total disregard paid to
them by the fever in its 12 years' march through Bardwan.
Thus, Dr. Jackson writes
—
"Malarious fevers are not infectious or contagious. They are
produced, in the neighbourhood where they prevail by the action
of the sun on a moist soil. ......... Malarious fevers cannot travel;
they may be blown to a certain distance, or may diffuse to a certain
distance, which is very limited."
Again Dr. Wilkie says
—
"In the writings of those who have maintained the malarious
nature of the disease, there is a very general absence of all reference
to the subject of contagion, probably because the malarious nature of
the fever was accepted as a guarantee of its non-contagiousness."
Thus we see, just as has been the case in Assam with
regard to kála-ázar, those who looked on the fever as malarial
held that it could therefore not be communicable, while Dr.
Jackson, who seems to have been the first to recognise
that its steady spread could only be accounted for on the
supposition that it was communicable, aragued that for this very
reason it could not be entirely malarial in its nature. Later,
when the disease travelled across the Bardwan district
into Beerbhoom and Midnapur, it was recognised that, although
malarial, it was communicable, but no satisfactory solution
of the difficulty was offered; and I believe it is generally
recognised to this day that it has never been fully explained.
Resemblances between Assam and "Bardwan Fever". 187
I hope, however, to be able to show in the next section how
this problem, both in the case of the "Bardwan fever" and
"kála-ázar" which was insoluble in the, from the scientific
point of view, dark ages of a quarter of a century ago, can
now be easily explained by the light of mordern bacteriology,
although it will not be capable of complete demonstration
until the malarial organism can be cultivated outside the
body in laboratories. The evidence as to the communicability
of the Bardwan fever must be first given. It is unnecessary
here to discuss the many theories which were put forward to
account for this epidemic by purely local alterations of the
country affected, either by a hypothetical wave of "gradual
elevation of the fever tracts from east to west," or an
equally unproved" river elevation above the intervening land,"
while the various river and railway embankments to which
were attributed the outbreak, not only were totally inadequate
to affect the large areas involved in which they were but as
mole-hills, but they were crossed in all directions by the
advancing wave of fever without any relationship whatever
to their influence on the drainage of the tracts. It may
safely be said that such obstructions as did exist were far too
local to account for a tithe of the area affected, while the one
theory which approximately covers the area involved, namely,
that which attributes it to the successive elevation of the
rivers from Jessore in the east to those of Midnapur and
Beerbhoom in the west, is not only totally without any proof
that such a thing took place during the time of the epidemic,
but is entirely negatived by the sequence in which the
various areas were affected, bearing no accurate relationship
to the supposed cause.
On the other hand, there is abundant evidence that the fever
travelled steadily along "lines of communication," subject,
however, to the controlling influence of another factor, namely,
a soil on which many malarial fevers naturally flourished.
This last all-important factor has been already illustrated, and
it has been shown that to this alone was due the cessation of
2 B 2
188
Report on Kála-ázar.
the spread of the epidemic when it reached the laterite and
rocky soil of Midnapur and Western Beerbhoom, respectively.
The former remains to be illustrated by abstracts from the
accounts of the epidemic.
In 1872, Dr. French, after recording it as his opinion
that the disease was an intense form of a malarial fever, which
local conditions were not sufficient to account for, writes
—
"There is one thing certain about the fever,—it progresses
steadily, although slowly; in some years it has come east and south
- e a s t , r e g u l a r l y w e s t a n d n o r t h - w e s t ; i t h a s f o l l o w e d l i k e a c o n i n g
wave, the chief roads and lines of communication; and it is steadily
going on to the west and north-west."
And he compares it with the epidemic fever in the Mauritius
of 1866-67.
In 1875, the Civil Surgeon of Serampore (in the Hooghly
district) writes—
"There is no doubt that the fever seems to follow the tracks of
the main and branch roads of the district originating at Jehanabad, on
the other side of the Damuda; the disease can be distinctly traced
along the old Benares road, which ends at Sulkea above Howrah.
There is no doubt that the fever has been carried along this road
to Howrah."
And he illustrates these remarks by a map. Dr. Barker,
of Beerbhoom, considers that
—
"the fever could not have been generated where it prevailed, but
must have been introduced from Bardwan either through intercourse
or the atmosphere."
And again—
"These insanitary conditions came about very gradually; and
as until recently the health of the people has been good, they cannot
be said to be the existing causes of the epidemic, although they may
be predisposing causes. It is hard to disassociate oneself from the
early teachings of science, but facts are stubborn things, and plainly
point to the fever being communicable."
In Midnapore the Civil Surgeon, Dr. Mathews, did not
agree with Dr. Jackson that the fever is propagated by human
intercourse.
"He instances the town of Midnapore, where hundreds of people