NationalLibraryOfScotland/medical-history-of-british-india huggingface dataset:
Resemblances between Assam and "Bardwan Fever". 189
had fled from the surrounding villages that were suffering from the
epidemic, yet this crowded, and by no means clean, village escaped
the fever."
But the Magistrate, Mr. Harrison, did not concur with
Dr. Mathews, for he writes
—
"I do not see anything in this district to confute Dr. Jackson's
views, while there is much to confirm them. It is plain in the face of
it, that the progress of the fever is directed by other agencies
besides contagion."
And he points out that Midnapore is situated on the
laterite soil, and that no places, except quite on the outskirts
of this tract, had been attacked, the whole of which had been
for 15 months in immediate contact with the fever-infected
parts, so that "it may be inferred that this tract is at least
adverse to its spread, if not altogether fatal to it," as it
subsequently proved to be. But he writes:
"Assuming that other agencies which appear to be of some natural
character beyond human control, determine its general progress, there
are many facts to show that contagion accelerates its march. In
every instance that I call to mind, the outposts of the disease, if I
may so say, of the fever have been on roads, and constantly traversed
by traffic."
This seems to be an instance of a non-medical man, un
-trammelled by "the early teachings of science," seeing more
clearly than the doctor. But it is in the elaborate report of
Dr. Jackson that the most convincing evidence of the com
-municability of the disease is given, and he goes further than
the others, and shows how the infection is carried. Thus, he
writes, in the account of his tour in the affected districts in
1873—
"Neema I found to be a very insignificant little village of only
nine houses, containing at the time of my visit 65 people; but during
the preceding year, 1872, there had been 21 deaths. The people's
account of the visitation was this: In May 1872, some men belonging
to the village, who had been employed in the country south of the
More, where fever was prevalent, returned sick with fever to the village.
The other inmates of their houses then began to suffer, and in a little
time all the inhabitants were attacked. Some of them had friends in
Report on Kála-ázar.
Kotasore (2 miles west), and asked them to come and nurse them; but
those who came were also attacked, and returned with the fever on
them to Kotasore, hitherto free from the disease, and it began to spread
there in the same manner. This was a volunteered statement, and the
people evidently believed that the disease had been imported into
Neema, and thence carried to Kotasore. In Kotasore, which contains
about 60 houses and 300 inhabitants, the people assured me that
the disease first appeared in the houses of some persons who, having
gone to Neema to see sick friends, had returned with fever, and intro
-duced the disease among them. There had been thirty deaths,and both
here and at Neema many people were ill at the time of my visit."
He gives several other similar instances, all of which
were volunteered statements. Another very instructive case
is the following:
"In Kotulpore, a thana recently transferred from Bankoora
to the Jehanabad (and fever) subdivision of Bardwan, a
very rapid spread of fever occurred in 1873, which was attributed
by the people to importation from the infected subdivisional station
to which they were, in consequence of their recent transfer from
Bankoora to Bardwan, really compelled to repair for the transac
- t i o n o f o f f i c i a l a n d l e g a l b u s i n e s s , a n d I a m a s s u r e d t h a t t h i s b e l i e f
was so strong among them, that numbers preferred losing their
suits to incurring the risk of visiting Jehanabad."
Again, he writes—
"It must be borne in mind that there is a kind of intercourse
between infected and uninfected villages, which is the neces
-sary consequence of the prevalence of the fever. Sickness and death
during the outbreak put so many of the labouring classes hors
de combat , that much of the annual crop would be lost, unless
extraneous assistance were procured. For this purpose, the
neighbouring uninfected villages are resorted to; a few labourers
are obtained from each of the places around, and it is a common
history that the people so employed return to their own houses
with the fever, and introduce it among their own people."
Again, Dr. Jackson also records much evidence to prove
that the houses become infected. Thus, he writes
—
"In Sheopore, in twelve consecutive, but separate, houses, only
3 out of 50 died; in the next group of 12 closely-built houses,
of which two were empty, 33 out of 55 died."
Resemblances between Assam and "Bardwan Fever". 191
Once more
—
"I have noticed that when deaths from this cause (the epidemic
fever) occur during the year of invasion, there are deaths in the
same houses in the following year in more than half the number of
cases noted."
To turn from the specific to the general, he sums up as
follows:
"During the eight years succeeding the introduction of the fever
into Culna, the disease spread steadily westward so long as the roads
and traffic lines were westerly. When these began to run north and
south, the disease took the same course, and its whole history exhibits
a remarkable and persistent association with the lines of communica
-tion. There has never been any such connection between the direc
-tion of its propagation and that of the lines of drainage. Two areas
have escaped the disease, of which the distinguishing features are as
follows:—One is low, moist, fertile, contains the average district
population per square mile, is purely agricultural, belongs to the
district of Moorshedabad, and has no road connecting it with the
fever tracts of Bardwan or Beerbhoom, and no traffic with those
districts. The other is somewhat higher and drier than the average,
is unfertile and sparsely populated (492 per square mile) as com
-pared with the average of the district, which is 578 per square mile,
and has no road crossing it, save a mere track. North and south of
the area, where there are roads and traffic, there has been fever also.
West of the former area, along the read line, there is fever also. In
the areas themselves, which resemble each other closely in no parti
-cular save their isolation from infected portions of Bardwan, there has
been no fever whatever. The exemption of these areas under the
conditions mentioned, is corroborative of the conclusion that the
disease spreads by importation and communication from and between
attacked and healthy villages. The fever then is a travelling fever.
It appears, spreads, prevails for a certain time, and disappears."
He sums up his opinion as to the nature of the fever
thus:
"I believe that a fever originally malarious, acquired either
Jessore or Nuddea contagious properties; that in virtue of this
contagion, it travelled westward into Western Nuddea."
And he traces it from here to Bardwan, and continues
—
"From his time its history is that of a travelling contagious
192 Report on Kála-ázar.
fever, intensified by crowding, receiving an accession of strength
and malignancy in every large town it visited, and proving most
fatal wherever people and villages were most concentrated. Wherever
there has been active intercourse, the fever has travelled; where
there has been little or none, it has died out."
And again
—
"It will be seen from the foregoing remark that, while I believe the
fever to be malarious in its origin, and to have some malarious
characteristics, I blieve it to be not a mere or simple, but a contagious,
malarious fever, that is, probably typho-malarial; and that it has not
been produced in Bardwan, but imported and again carried from
Bardwan into Beerbhoom, and its behaviour under the various
conditions observed are quite incompatible with its being simply
malarious, locally produced, or non-contagious.
I have quoted thus largely from the reports on the
Bardwan fever, because I am so convinced that the epidemic
of malarial fever which devastated several districts of Lower
Bengal in the sixties and early seventies, is a phenomena so
precisely similar to the epidemic fever which has traversed
Assam during the last twenty years, that, although I have
shown it had a different origin and was also of a different type,
yet I am prepared to go so far as to say that any explanation
of kála-ázar, which will not also be applicable to the "Bardwan
fever," will not be satisfactory. Moreover, the facts which
have been recorded concerning the Lower Bengal epidemic
prove conclusively that the Assam outbreak is not the first time
that malarial fever has attained to the power of communica
- b i l i t y , a n d i n t h e f o r m e r i n s t a n c e , t o o , t h e e p i d e m i c w a s s t a r t e d
as far as the imperfect records of that time allow of an opinion
to be formed on the subject, by extraordinary conditions
brought about by an unusually rapid silting-up of the Bhairub
river.
(193)
SECTION IX.
CONCLUSION AS TO THE NATURE OF THE EPIDEMIC
AND THE METHOD OF INFECTION.
We have seen that the epidemic which goes by the name
of kála-ázar in Assam is from first to last a very intense form
of malarial fever. We have seen that the whole course and
distribution of the disease has been that of a wave of increased
mortality from fever, which has slowly, but surely, spread up the
Assam Valley in the lines of communication, and that conclu
-sive evidence has been given to prove that the fever is spread
by being actually communicated directly or indirectly from
one person to another: in a word, that it is infectious. We have
seen that there was a definite cause for the intensification of
the ordinary malarial fever in Rungpore in the early seventies,
and that, as a matter of fact, the Assam epidemic did take its
origin from the spread of this intensified Rungpore fever across
the Brahmaputra by the two main lines of communication bet
-ween that district and the foot of the Garo Hills, where it first
attracted attention under the name of kála-ázar, or black
sickness. We have also seen that the epidemic of malarial
fever which devastated parts of Lower Bengal in the sixties
and early seventies, was of a precisely parallel nature to the
Assam epidemic, although it was of a different type and had a
different origin, and doubtless other historical epidemics of
malarial fever for centuries back were of the same nature,
although this is the first time that such a phenomena has been
examined in the light of modern pathological and bacteriologi
-cal knowledge, for the latter was still in its infancy at the time
of even the Bardwan epidemic, and the malaria germ was then
undiscovered. The question remains whether the facts ad
-duced in this report, when viewed in the light of our present
knowledge, will allow of an intelligible and comprehensive solu
-tion of the problem presented by the disease, such as will
2 C
194 Report on Kála-ázar.
furnish a rational foundation for the consideration of preventa
-tive measures.
To make the matter as clear as possible, I will first state
exactly what I believe to be the nature of the epidemic, and
then discuss the propositions that are involved in this view of
the disease.
Kála-ázar is, I believe, an epidemic of malarial fever, which
originated in an intensification of the ordinary malarious fever
in the Rungpore district in the early seventies by an extra
-ordinary succession of unhealthy seasons, until it attained to
the powers of infection; and that it has spread for the last
twenty years slowly up the Assam Valley as in a wave of
increased mortality due to this intense communicable type
of malarious fever, having found in the districts which it has
traversed a suitable soil for its propagation.
This view involves the following propositions: (1) that
malarial fever may, under exceptional circumstances, become
intensified to such a degree as to attain to epidemic proper
-ties; (2) that malarial fever when it has become sufficiently
intensified and is introduced into a suitable soil, may spread in
an epidemic form over considerable areas, and cause an ex
-ceptionally great mortality, in the absence of any changes in
the physical or sanitary condition of the places affected;
and (3) that the germs of the disease must in some way be
able to get out of one person into another, either directly or
indirectly, after passage through the soil, which is obviously
necessitated by the conditions of the second proposition.
The first of these propositions requiries very little argu
-ment, as the facts given in the last section regarding the
"Bardwan fever," which was of an admittedly malarious nature,
is alone sufficient proof of its truth, while many other instances
in which malaria has become epidemic are on record. It is
also well known that malarious fevers vary very much in their
intensity in different places, and in different years in the
same place. When we talk of an unhealthy year in India,
we usually mean one in which the mortality from malarious
Nature of epidemic and method of infection.
195
fevers was unusually high. The probability is that such a
year will be succeeded by one that is comparatively healthy.
But suppose that on the top of one very malarious year an
-other similar to it should succeed, as occasionally occurs,
then we find the death-rate from fever increases very greatly
both in its prevalence and its fatality, in other words, in its
intensity. Now, suppose it should happen that a third bad
year should immediately follow the other two—a coincidence
that must fortunately be exceedingly rare—would it not be
expected, nay, would it not be certain, that an excep
-tional outbreak of malarial fever of a very intense type would
result, and is it not conceivable that it might even attain to
such an intensity as to actually become communicable? But
I have shown that the Assam epidemic fever originated in a
succession of four out of five such unhealthy years.
The second of the above propositions is the most import
-tant and essential to my argument. In the case of the Assam
and Lower Bengal epidemics of malarial fever, the communi
-cable type was introduced into places where malarious fevers
were already only too prevalent, although not previously
epidemic, namely, the foot of the Garo Hills, and in Nuddea and
Bardwan, etc., respectively, so that the difficulties of demon
-strating my second proposition in these instances are well
nigh insuperable. If, however, it can be shown that mala-
rious fever has been introduced by human intercourse into any
place which was previously free from it, and that, when so intro
-duced, it spread in the form of an epidemic, for which purpose
the germs of the disease must necessarily pass from one person
to another and be introduced into the soil from the bodies of
the carriers of the disease, then both the second and third of
my propositions will be demonstrated. Now, there are cer
-tain parts of the world, mostly islands, in which malaria is
unknown in spite of a climate and soil which appear to be
most favourable to its development, and its absence can
only be accounted for on the supposition that the malarial
germs have never been introduced into the soil. There
2 C 2
196
Report on Kála-ázar.
is also an instance recorded within modern times where
malarial fever did become introduced into two islands that
were previously free from it; I refer to the well known in--
stance of Mauritius and Réunion, Up to 1865, malarial
fever was unknown in them, although low-lying, undrained,
marshy land abounds, more especially on the leeward side
of Mauritius. In 1865, malarial fever was introduced into
the island by coolies from India, and this, be it remarked,
at the very time when the Bardwan fever, which was an
intense communicable type of malaria, was raging in parts
of Lower Bengal, and it is recorded that such a fearful epi-
-demic ensued that one-third of the inhabitants of the island
are said to have died in the course of four years, while
out of a population not exceeding 130,000 in the area affected,
the deaths in 1867 were 31,920. Moreover, the disease is
there in an endemic form to the present day, although the
neighbouring island of Rodrigues is still free from infection in
spite of its being under precisely the same climatic conditions.
The fact that this island is still free from malaria, points to the
conclusion that when the epidemic subsided in Mauritius, the
fever lost its communicability, and therefore its power of
being introduced into new places, at the same time that
it lost its abnormal intensity. Here, then, at all events,
the malarial germs must have been introduced into the
soil of the island from the imported coolies who brought
the disease, and finding a suitable nidus for their develop
- - m e n t , a n d p e o p l e w h o w e r e v e r y s u s c e p t i b l e t o t h e p o i s o n
they were able to rapidly spread themselves over the island,
and to cause the worst epidemic of malaria recorded in
modern history. This being the case, it is evident that
malarial fever is capable of attaining to the power of at least
indirect infection through the soil, as it must have done so,
in order to infect the islands of Mauritius and Réunion; and
I think the evidence that I have produced in this report
proves that it has also done so in the case of the epidemic
fever of Assam, and doubtless also in the Bengal outbreak,
Nature of epidemic and method of infection.
197
so all difficulties in the way of accepting this view of the
disease vanish.
It may be at once admitted that this is quite contrary to all
the old ideas on the subject of malaria; but, on the other
hand, it is easy to show that it is in accordance with all the
teachings of modern bacteriology, and is also very strongly
supported by analogous instances in the case of some of the
other germ diseases. Thus, in the first place, it is an estab-
lished principle of bacteriology (and one on which both
Pasteur's inoculations against hydrophobia and Haffkine's
against cholera are based) that any pathogenic germ which can
be cultivated or passed through suitable animals, can be
artificially intensified without any marked changes in its shape
or appearance; and what is of more importance still, when it
has once been so intensified, it can be inoculated from one
test-tube to another for generations under favourable condi
-tions without any marked loss of its newly-acquired powers.
In precisely the same way I maintain that in the case of
travelling epidemics of malarial fever, the germs have become
intensified, as it were in Nature's laboratory, by unusually
favourable conditions, until they attain to the power of
being communicated from one person to another, either
directly or indirectly, after passage through the soil; and
that when once this power has been attained, an epidemic
is started, which may go on spreading from one district to
another for years without any alterations in physical or
sanitary conditions of the affected places, as long as it finds a
suitable soil for its multiplication and people whom it may
attack, or until it loses its intensity owing to any un
-favourable conditions. Unfortunately it will be impossible to
scientifically demonstrate this proposition until the malarial
organisms can be artificially cultivated (which it would have
been only a waste of time for me to attempt under the con
-
ditions in which my work was necessarily carried on, seeing
that all efforts in this direction, which have been made in the well
-
appointed laboratories of Europe by the most skilled bacterio-
198
Report on Kála-ázar.
logists, have hitherto failed to produce this very desirable re
-sult). We may, however, consider if there are any analogous
instances of diseases produced by other germs, which are not
ordinarily infectious, becoming so when intensified in any
natural way, for even a single example of this taking place
would lend great probability to the same being possible in the
case of malaria. Here again, there is evidence at hand, for
pneumonia (inflammation of the lungs), which is now pretty
generally acknowledged to be caused by Fraenkal's pneumo
-coccus, is not ordinarily an infectious disease; yet every
now and then it becomes so, and attacks whole families,
or, as has occasionally been seen on the North-West frontier
of India, a large number of a regiment, the sick attendants put
over cases even contracting the disease. Moreover, when
it is thus infectious, it is also very fatal or intense. Again, if
the recent views with regard to plague be verified, as seems
very probable, then there is a mild non-infectious and seldom
fatal form of the disease which goes by the name of pestis
minor, while there is also the well-known communicable and
very intense and fatal form now so serious in the Bombay
Presidency, which arises by an intensification of the mild non
-infectious form, possibly through the passage of the virus
through the rat or other very susceptible animal.
There is then nothing inherently improbable in this view
of the disease, while it is strongly supported both by what
is known by analogous germ diseases, and by all the
doctrines of recent bacteriological research. Moreover, it
fully explains all the mystery surrounding both the Assam and
Lower Bengal outbreaks of epidemic malarial fevers, in a way
that no other view of either disease does, that is in consonance
with the facts.
The way in which the germs get from one person to
another, and the reason of the decrease of the affection in
any given place after a few years, remain to be considered.
Abundant evidence has been given in Section VII to show
that it is generally necessary for a person to live in or visit an
Nature of epidemic and method of infection.
199
infected house or village in order to contract the fever. It
was also shown that the disease usually begins in one place by
a person who has contracted the fever in another coming to
live in the uninfected village, and that the next cases occur
in the same house as he is residing in, and then it spreads
to others, often those who frequently visit the first cases
when ill, being the next to suffer. The majority of new
cases begin during the rainy season, and there is always much
less fever in the cold-weather months, when the ground is
dried up. Further, the infection sticks to houses and the soil
of affected villages, and, in a few instances, where the inhabit
-ants of an entire village or coolie lines have been moved to a
new site, which may be only 200 yards from the old one, dur
-ing the cold-weather months, when the fever is at a minimum,
then the disease has not broken out in the same way among
them during the ensuing rainy season, as it had in previous
ones. This shows that they had left the infection behind them
in the soil of the old village site. How can all these facts be
explained? It is evident that the malarial germs must escape
from the bodies of those who are suffering from the fever in
some way or other. Dr. Patrick Manson and others have
recently suggested that this takes place in ordinary malaria
by mosquitoes sucking up the blood from infected persons,
and then going and dying in water in which the germs
contained in the blood that they have extracted escape
and multiply. Although Surgeon-Major R. Ross has recently
published some interesting experiments on certain changes
which the crescent-shaped form of the parasite goes through in
the stomach of the mosquito, there is as yet very little evidence
in favour of Dr. Manson's ingenious idea; and, although
I have constantly borne it in mind, I have not met with any
facts in the course of my investigation that lend support
to it. On the contrary, it would be very difficult or impos
-sible to explain the facts that I have adduced as to the
infection in kála-ázar on this hypothesis, while the crescent-
shaped bodies are not met with in kála-ázar, and even