February
THE FEVERS OF BRITISH BURMA.
1,1878.]
THE FEVERS OF BRITISH BURMA. from "fever" in British
The great
mortality
dicated
the mortuary returns, has
by
Burma, as repeatedly attracted
Commission.
attention of the Army Sanitary
capacity
us
the
88'00 per cent., and the death-rate from of population from 2-71 to 17 '90. In the
to
of the
"
"
or
ever
was
the Burmans and the
absence of all appearance of malarial cachexia among them? circumstances whijh contrasted very strikingly with what
province during the same year the proportion of fever deaths to total deaths, was 6'89 per cent., and the rate per 1,000 of prisoners, 0 42. This very striking difference is unhesitatingly attributed by Surgeon-Major W. P. Kelly, the compiler of the report, to the ignorance and carelessness of those The ignorant village head who collect vital statistics." in each village," it is said, "invariably deaths record who men, attribute to fever all deaths resulting from diseases attended with febrile symptoms as indicated by a hot skin, quickened respiration, or delirium?deaths from pneumonia, for instance, which is a more common disease than is generally thought amongst the inhabitants of this country, being invariably attributed to fever." When the simple numeration of deaths is so imperfect as this report indicates, it is not to be wondered at that the diagnosis and return of the causes of death is utterly As long as the agents, to whom this task and absurdly wrong. is entrusted, remain as ignorant and incapable as they are, so long will the assigned causes of death remain valueless. The only wonder is that, with such an agency, the attempt to register causes of death is at all made, or that the results are solemnly tabulated, manipulated and commented upon, as if they were jails
of
the
We have now
sanitary report
?varied from 12-21
On his arrival in Burma he
struck with the
and the remarks of the Army
"fever" per 1,000
Surgeon.
"splendid physique"
in->
of the province for the year 1875, Sanitary Commission thereon, which contain important and interesting information regarding the fevers of British Burma, a brief precis of which we propose to record. It appears that of 40,570 deaths registered in the province during the year 1875, 25,075, or 62'11 per cent, of the " whole, were attributed to fever"?constituting a mortality of of the The proportion which fever population. 8-74 per 1,000 deaths bore to total deaths in the different registration circles before
of Police
47
could become, under the circumstances, otherwise than
absolutely worthless, if not?worse than worthless?misleading. The only plea for the system is, that it furnishes the means of educating the people in mortuary registration; but, until educated agents are forthcoming, capable of recognising even the few simple causes of death which the present mortuary return forms require, we ought to be content with confining our attempts to simple numeration, which is possible, but is very far from being a'ccomplished. The report under notice contains, however, information of a more valuable kind than these ridiculous figures afford. At tb e instance of the Army Sanitary Commission, reports on fever had been called for from the Civil Surgeons of Burma, and among these a very careful paper was received from Surgeon A. Crombie, M.D., Junior Civil Surgeon of Rangoon, which the Sanitary Commissioner has considered worthy, and with reason, to be embodied in his report. A priori, Burma " with its heavy rainfall, large tracts of low-lying lands which are inundated during the rains, thick vegetation and low-lying deltas, must bo a hotbed of malaria, but it is not so." Dr. Crombie's experience of fever was confined to the Rangoon Central Jail, containing over 2,000 prisoners, and the immigration depot hospital, but he supplements that with post-mortem operations made in his
he had observed in the had
Gangetic Delta
where his
The observations in the Jail
been.
previous service Hospital?and these
investigations, report?demonstrated that
included careful thermometric
given
are
in the
fever in the nued fever
charts of which "
the commonest
Rangoon Jail is undoubtedly febriculn, a contiof only three or four days' duration, and probably
upon exposure to the sun or to cold or some other unknown cause." Cases of genuine ague, assuming occasion-
depending ally
a
remittent type, came next; but instances of pure remittent
Dr. Kelly endorses, as regards the progenerally, the conclusions drawn from the Rangoon The prevailing fevers of the country are," he Jail Hospital. states, principally febricula and quotidian intermittent of a mild type ; but in certain localities, Mendoon, in the north of Pegu, and the Yonzaleen for instance, paludal fevers of a
fever were very rare. vince
"
"
severe
and
tively at
type, attended with cerebral symptoms,
no doubt occur, very rapidly fatal ; but these localities are comparafew, and are welj known places situated on low hills
are
the foot
of
high
mountains
or spurs leading from the experience of Dr. Griffiths, for many years Civil Surgeon of Rangoon, is very much to the same He thinks that " quotidian intermittent fever is the effect. most common, that all the types of fever in the Rangoon district, with one exception, are mild, the exception being in the case of fever which is endemic in the village of Tan-manine, where there are extensive salt kilns: the people attribute the disease there to impure water in the tank, which is the only source of supply, caused by the ashes from the burning salt kilns being wafted into it." He adds that "fevers complicated with disease of the abdominal viscera are seldom met with ; but that lung complications are common, and that pneumonia is, in his opinion, the most prevalent and fatal of all diDeaths from it are of course seases occurring amongst Burmans. invariably returned by the town and village registrars as having been from fever." The statistics of the British Ar" feverish" my in India indicate that Burma is by no means a while the five for, during province; years, 1871?75, the rate
mountain ranges."
The
of admissions from intermittent was 319 8 per 1,000 for the whole army, the corresponding rate of that section of it cantoned
The corresponding rates of remittent 152-7 against 72-36. The death-
in Burma was 443*16. and
continued fever were
rates were 0-07
against 0'
and 1*1
against -49. Dr. Crombie'spostopinions. In 145 autopsies he four instances, or 2 75 percent.
mortem observations confirm these
only
found the
spleen enlarged
in
Two of these four wore natives of India and one
a
Chinaman. The
subjects were persons dying "under every variety of condition." It is interesting to place in contrast with these figures similar observations made in the district of Jessore, and recorded in Volumes III and IV of this journal. Among fifty postmortem examinations, the spleen was only found healthy in The organ two cases. 'Its average weight was about 14ozs. was enlarged in thirty-three cases, engorged in twenty-one, indurated in thirteen, capsule opacified in fifteen, adhesions in four, ruptured one, capsule cartilaginous in four, and the organ pigmented in two cases. a
The author states that he had not seen
perfectly healthy spleen since ho came
to
India.
The immi-
THE INDIAN MEDICAL GAZETTE.
48
gration depot hospital furnished experience of a different kind. "The immigrants are mostly natives of Lower Bengal, and they thrive very badly in Burma, and the twenty to thirty men who are always in the depot hospital are probably the most miserable looking creatures on this side of the Bay. They present every variety of the evidence of malarial poisoning. Cases of pure ague, with severe cold and hot stages, are by no means rare, and although I have had charge of the hospital only for a few months, I have had several cases of chronic enlargement of the spleen, or three of the anasarca, which is a feature in the worst forms of the malarial cachexia." The evidence above cited indi-
and two
cates, if it does not demonstrate, that malarious fever i3 neither common nor severo in Burma among the Burmane, but that natives of Bengal suffer severely from malarious poisoning when transferred there. Dr. Crombie attributes this difference between the morbific influence of the Deltas of the Ganges and Irrawaddy to the fact that the former is
composed geologically
of recent
alluvium annually soaked and added to by an inundation depositing a substantial layer of silt, while the latter consists of an older alluvium raised from the sea bottom where it was originally
deposited, and which is scoured by obstructed hill streams tempo" The rarily dammed up in the rains by the flooded Irrawaddy. Ganges," he writes, "is a depositing, while the Irrawaddy is an excavating, river." He also hints that the raising of native houses on piles may have something to do with the immunity from fever and its mild type, but this condition is not universal, and the raising amounts in many cases to only a few feet. The Army Sanitary Commission suggest that
an
endeavour should be made to ascer-
comparative proportion of fever cases among people ?who sleep on the ground level, and those who sleep on raised From the floors. The inquiry would be a very difEcult one. facts, as set forth in the report, they draw the conclusion that " excessive rainfall is not necessarily accompanied with fatal paludal fevers in tropical climates, and the Burmese experience
tain the
confirms in another way the observations made in India that the chief danger lies in the state of the sub-soil after rain. If the rainfall water logs the sub-soil, the first condition for the production of malarial fever is present, whatever the amount of rainfall may be. In Burma inquiry might easily be made as to what becomes of the rain. It seems probable that it escapes the surface or drains
readily through the subsoil?in any stagnate, except in specially unfavourable localities, and in such, where they exist, it would be important for sanitary work to ascertain the comparative amount and character of fevers which prevail. The facts, as they stand, appear to point to the conclusion that the heavy rainfall could be best removed by improved surface drainage when needed, and that in a few exceptional localities only would drainage operations, properly so called, be required." Nothing, in what of malarious fevers, is more certain we know of the etiology on peculiar conditions of water and soil, or, than that they depend more correctly perhaps, sub-soil ; and we entirely endorse the opinion of the Army Sanitary Commission that the accurate definition of these conditions can best be obtained by a thorough investigation of the geology and drainage of fever-free over
case
that it does not
contrasted with others where malarious fevers are
localities
as
prevalent
and severe.
[February 1, 1878.
THE FEVERS OF BRITISH BURMA.
1,1878.]
THE FEVERS OF BRITISH BURMA. from "fever" in British
The great
mortality
dicated
the mortuary returns, has
by
Burma, as repeatedly attracted
Commission.
attention of the Army Sanitary
capacity
us
the
88'00 per cent., and the death-rate from of population from 2-71 to 17 '90. In the
to
of the
"
"
or
ever
was
the Burmans and the
absence of all appearance of malarial cachexia among them? circumstances whijh contrasted very strikingly with what
province during the same year the proportion of fever deaths to total deaths, was 6'89 per cent., and the rate per 1,000 of prisoners, 0 42. This very striking difference is unhesitatingly attributed by Surgeon-Major W. P. Kelly, the compiler of the report, to the ignorance and carelessness of those The ignorant village head who collect vital statistics." in each village," it is said, "invariably deaths record who men, attribute to fever all deaths resulting from diseases attended with febrile symptoms as indicated by a hot skin, quickened respiration, or delirium?deaths from pneumonia, for instance, which is a more common disease than is generally thought amongst the inhabitants of this country, being invariably attributed to fever." When the simple numeration of deaths is so imperfect as this report indicates, it is not to be wondered at that the diagnosis and return of the causes of death is utterly As long as the agents, to whom this task and absurdly wrong. is entrusted, remain as ignorant and incapable as they are, so long will the assigned causes of death remain valueless. The only wonder is that, with such an agency, the attempt to register causes of death is at all made, or that the results are solemnly tabulated, manipulated and commented upon, as if they were jails
of
the
We have now
sanitary report
?varied from 12-21
On his arrival in Burma he
struck with the
and the remarks of the Army
"fever" per 1,000
Surgeon.
"splendid physique"
in->
of the province for the year 1875, Sanitary Commission thereon, which contain important and interesting information regarding the fevers of British Burma, a brief precis of which we propose to record. It appears that of 40,570 deaths registered in the province during the year 1875, 25,075, or 62'11 per cent, of the " whole, were attributed to fever"?constituting a mortality of of the The proportion which fever population. 8-74 per 1,000 deaths bore to total deaths in the different registration circles before
of Police
47
could become, under the circumstances, otherwise than
absolutely worthless, if not?worse than worthless?misleading. The only plea for the system is, that it furnishes the means of educating the people in mortuary registration; but, until educated agents are forthcoming, capable of recognising even the few simple causes of death which the present mortuary return forms require, we ought to be content with confining our attempts to simple numeration, which is possible, but is very far from being a'ccomplished. The report under notice contains, however, information of a more valuable kind than these ridiculous figures afford. At tb e instance of the Army Sanitary Commission, reports on fever had been called for from the Civil Surgeons of Burma, and among these a very careful paper was received from Surgeon A. Crombie, M.D., Junior Civil Surgeon of Rangoon, which the Sanitary Commissioner has considered worthy, and with reason, to be embodied in his report. A priori, Burma " with its heavy rainfall, large tracts of low-lying lands which are inundated during the rains, thick vegetation and low-lying deltas, must bo a hotbed of malaria, but it is not so." Dr. Crombie's experience of fever was confined to the Rangoon Central Jail, containing over 2,000 prisoners, and the immigration depot hospital, but he supplements that with post-mortem operations made in his
he had observed in the had
Gangetic Delta
where his
The observations in the Jail
been.
previous service Hospital?and these
investigations, report?demonstrated that
included careful thermometric
given
are
in the
fever in the nued fever
charts of which "
the commonest
Rangoon Jail is undoubtedly febriculn, a contiof only three or four days' duration, and probably
upon exposure to the sun or to cold or some other unknown cause." Cases of genuine ague, assuming occasion-
depending ally
a
remittent type, came next; but instances of pure remittent
Dr. Kelly endorses, as regards the progenerally, the conclusions drawn from the Rangoon The prevailing fevers of the country are," he Jail Hospital. states, principally febricula and quotidian intermittent of a mild type ; but in certain localities, Mendoon, in the north of Pegu, and the Yonzaleen for instance, paludal fevers of a
fever were very rare. vince
"
"
severe
and
tively at
type, attended with cerebral symptoms,
no doubt occur, very rapidly fatal ; but these localities are comparafew, and are welj known places situated on low hills
are
the foot
of
high
mountains
or spurs leading from the experience of Dr. Griffiths, for many years Civil Surgeon of Rangoon, is very much to the same He thinks that " quotidian intermittent fever is the effect. most common, that all the types of fever in the Rangoon district, with one exception, are mild, the exception being in the case of fever which is endemic in the village of Tan-manine, where there are extensive salt kilns: the people attribute the disease there to impure water in the tank, which is the only source of supply, caused by the ashes from the burning salt kilns being wafted into it." He adds that "fevers complicated with disease of the abdominal viscera are seldom met with ; but that lung complications are common, and that pneumonia is, in his opinion, the most prevalent and fatal of all diDeaths from it are of course seases occurring amongst Burmans. invariably returned by the town and village registrars as having been from fever." The statistics of the British Ar" feverish" my in India indicate that Burma is by no means a while the five for, during province; years, 1871?75, the rate
mountain ranges."
The
of admissions from intermittent was 319 8 per 1,000 for the whole army, the corresponding rate of that section of it cantoned
The corresponding rates of remittent 152-7 against 72-36. The death-
in Burma was 443*16. and
continued fever were
rates were 0-07
against 0'
and 1*1
against -49. Dr. Crombie'spostopinions. In 145 autopsies he four instances, or 2 75 percent.
mortem observations confirm these
only
found the
spleen enlarged
in
Two of these four wore natives of India and one
a
Chinaman. The
subjects were persons dying "under every variety of condition." It is interesting to place in contrast with these figures similar observations made in the district of Jessore, and recorded in Volumes III and IV of this journal. Among fifty postmortem examinations, the spleen was only found healthy in The organ two cases. 'Its average weight was about 14ozs. was enlarged in thirty-three cases, engorged in twenty-one, indurated in thirteen, capsule opacified in fifteen, adhesions in four, ruptured one, capsule cartilaginous in four, and the organ pigmented in two cases. a
The author states that he had not seen
perfectly healthy spleen since ho came
to
India.
The immi-
THE INDIAN MEDICAL GAZETTE.
48
gration depot hospital furnished experience of a different kind. "The immigrants are mostly natives of Lower Bengal, and they thrive very badly in Burma, and the twenty to thirty men who are always in the depot hospital are probably the most miserable looking creatures on this side of the Bay. They present every variety of the evidence of malarial poisoning. Cases of pure ague, with severe cold and hot stages, are by no means rare, and although I have had charge of the hospital only for a few months, I have had several cases of chronic enlargement of the spleen, or three of the anasarca, which is a feature in the worst forms of the malarial cachexia." The evidence above cited indi-
and two
cates, if it does not demonstrate, that malarious fever i3 neither common nor severo in Burma among the Burmane, but that natives of Bengal suffer severely from malarious poisoning when transferred there. Dr. Crombie attributes this difference between the morbific influence of the Deltas of the Ganges and Irrawaddy to the fact that the former is
composed geologically
of recent
alluvium annually soaked and added to by an inundation depositing a substantial layer of silt, while the latter consists of an older alluvium raised from the sea bottom where it was originally
deposited, and which is scoured by obstructed hill streams tempo" The rarily dammed up in the rains by the flooded Irrawaddy. Ganges," he writes, "is a depositing, while the Irrawaddy is an excavating, river." He also hints that the raising of native houses on piles may have something to do with the immunity from fever and its mild type, but this condition is not universal, and the raising amounts in many cases to only a few feet. The Army Sanitary Commission suggest that
an
endeavour should be made to ascer-
comparative proportion of fever cases among people ?who sleep on the ground level, and those who sleep on raised From the floors. The inquiry would be a very difEcult one. facts, as set forth in the report, they draw the conclusion that " excessive rainfall is not necessarily accompanied with fatal paludal fevers in tropical climates, and the Burmese experience
tain the
confirms in another way the observations made in India that the chief danger lies in the state of the sub-soil after rain. If the rainfall water logs the sub-soil, the first condition for the production of malarial fever is present, whatever the amount of rainfall may be. In Burma inquiry might easily be made as to what becomes of the rain. It seems probable that it escapes the surface or drains
readily through the subsoil?in any stagnate, except in specially unfavourable localities, and in such, where they exist, it would be important for sanitary work to ascertain the comparative amount and character of fevers which prevail. The facts, as they stand, appear to point to the conclusion that the heavy rainfall could be best removed by improved surface drainage when needed, and that in a few exceptional localities only would drainage operations, properly so called, be required." Nothing, in what of malarious fevers, is more certain we know of the etiology on peculiar conditions of water and soil, or, than that they depend more correctly perhaps, sub-soil ; and we entirely endorse the opinion of the Army Sanitary Commission that the accurate definition of these conditions can best be obtained by a thorough investigation of the geology and drainage of fever-free over
case
that it does not
contrasted with others where malarious fevers are
localities
as
prevalent
and severe.
[February 1, 1878.
