Reg. No. 464, Med. Gaaetto.-2-12-90.-? 10. 1>hct0 ;3.I.0,0alcutta. Photo ; 8.1. O , Calcutta.

Re&. No. 464, Med. Gazette.?2-12-90.?710.

(?Htginal (Eommumcatiomi.

NOTES ON HILL MALARIA.

By Surgeon G. CAPEL HALL, i.m.s.

Up in the Chin Hills with only field kit, few books of reference, and without microscope, I

have found it difficult to attempt to do justice to this subject (being forcibly reminded of this by Dr. Banuerman's masterly resume of

the latest literature vide Indian Medical

Gazette, August 1890). However, with the read- er's indulgence, I will now make some comments on six months (April 1890 to end of September 1890) of observation and figures that I have

endeavoured to the best of my ability* to collate. The four posts of Fort White, No. 5 stockade,

No. 4 stockade and No. 3 stockade comprise our stations in the northern part of the Chin Hills. From Kalemyo (vide accompanying map), lying in what is known as theKaldValley to Fort White in the Chin Hills, the road is indicated by a black dotted line passing through No. 3 (No. 2 being abolished), and No. 4 posts, which are situated on a spur thrown out from a high range of mountains called the Letha Range (indicated by a thick black line), on the distal side of which is a semi-circular spur whereon Fort White is marked. This fort is on the side of the spur, height 5,000 ft. above sea-level, and the severe outbreaks of fever of 1889 and 1890 occurred here.

This year, our average strength 2-4 Gurkhas has been 360, decreasing in August to 170, but then reinforced by 150 of 38th B. I.

During the period, April to end of Septem- ber 1890, the total number of admissions for fever were as follows:?

Admissiom, Died. Invalided. 2-4 Gurkhas ... 735 3 25 To Myingyan for change

of air 61. 38th B, I. ... 132 0 To Myingyan for change

of air 11. Q. O.S. $ Miners 51 0 (Strength only 30 decreas-

ing to 25). To Man-

dalay for change of air 5, Followers ...107 2 (Strength about 60.) Unrecorded ... 50 Officers, civilians, &c., un-

Tota ...1,075 attached.

The other three posts may be dismissed in a few words.

No. 5, height 7,200 ft., strength 50-80, 2-4 Gurkhas, though cold and damp, was bracing. Number in hospital varied from 0 to 5 maxi-

mum, more dysentery aud diarrhoea than fever. No. 4, height 5,200 ft., strength 80 of 38th

B. I., who were relieved by 80 of 2-4 Gurkhas in August, aud these men coming on to Fort White, enabled me to definitely prove that

the malaria was not brought as I had first sup- posed might be the case, entirely from the Kale and other unhealthy valleys. From April to end of July 1890 the 38th

B. I. had enjoyed excellent health at No. 4, but the charts (black levels) shew the admis- sions just after arrival here. No. 3, height 3,700 ft., strength 80 of 38th B. I., garrison frequent- ly interchanged with that of Kalemyo?scurvy and dysentery prevailed rather than fever, al-

though at these posts Nos. 5, 4, and 3 a very heavy rainfall was recorded (once in a single day nearly 6 inches, frequently 2 or 3 inches); no relation whatever as to admissions can be traced.

Careful enquiry amongst the native Chins elicits the fact that fever is endemic all the year round in this valley, but is especially rife during the rainy seasons. As to the geology, the spur on which Fort

White is situated consists almost entirely of a light friable shale (laminae being very loose), with quartz in small quantities, its surface covered with finely powdered shale debris and in parts with a light vegetable mould (most fertile). Light scrub and grass jungle with a few fir trees grew formerly. The other posts are one and all on dense igneous rock, sandstone, &c. (Nos. 5 and 4 especially.) From thetopography of Fort White it appear-

ed that the old theory of malaria (as met with in marshy and undraiued lands) considered to be, in the concrete, as a ground emanation, in the abstract, as an entity caused by two main fac- tors, viz., soil plus water, could not possibly hold good here. The fort is on the slope of the spur, aud the natural drainage is admir- able, since the general rise is 1 in 4 or 15? and in many places steeper still, aud further more is perfected by many artificial trenches, necessarily of steep gradients, so that during heavy rain, small cataracts as it were, at once

carried off surplus water. However the theory is borne out by the

accompanying charts, shewing the relation be- tween rain plus something else (which I take to be soil), and an almost immediate increase of

daily admissions for fever. I can only suggest that the surface soil is porous and spongy enough to hold sufficient fluid to manufacture, so to speak, the emanation known as malaria ; or

if considered casually as the bacillus of Marchia- * Some experiences of malaria in the plains of Upper

Burma during 1887 and 1888 are also embodied here.

THE INDIAN MEDICAL GAZETTE. [Jan. 1891.

fara, Celli, and other observers, is then most

favourable to its development and multiplication. The charts speak for themselves and shew,

I think, more than mere coincidences. Explanation of monthly charts. Along the top line is the daily rainfall in

inches, taken at 8 A.M. on the morning of the date which is shewn along the bottom line. At the right hand is the actual number of fever cases that were admitted per diem, the levels in the daily columns correspond accordingly, being placed on the line of such numbers, lied levels refer to 2-4 Gurkhas and black ones to 38th B. I.

These latter only commenced in August, by the beginning of which month their full strength had arrived, and in August and September their charts are combined, e.g., on September 24th four 2-4 Gurkhas and one 38th B. I. were admitted. The maximum of fever cases admitted in one

day was 25 on 29th April 1890, probably,partly due to rain '6 inch previously, partly to fresh arrivals and partly to the march through the Terai.

May was a most malarious month; allowing for coincidences, the rises on lltli and 28th are noticeable. June?Same remarks apply ; rise of 17th in

particular. July?Rise of 24th at end of this month

note decrease of strength and a most distinct inoculation* or acclimatisation manifested it- self? all officers (7) ceased to have fever

by beginning of August (except Lieut. Battye, who however ceased in September); also many sepoys known tome personally; also with the followers and officers, orderlies and servants.

We seemed to become ' fever proof,' certainly this lasted to date of writing. That malaria was still prevalent is shewn by chart for August when 38th B. I. arrived.

August shews inoculation of 2-4 Gurkhas and suffering of 38th B. I., almost all of whom had been through hospital by the end of the month.

September shews continued inoculation of both regiments until very heavy rain on 20th, 21st, and 22nd, when four of each were soon ad- mitted on 24th and 25th. On 24th what seemed to me remarkable was the ' unrecorded list, numbering 7, and on 25th 3 as the majority had never previously suffered, but now did so and severely too.f

Further I hope, at some future time, to print many temperature charts, shewing, in the case of chronic intermittents and convalescent re-

mittents, how invariably a heavy rainfall is as- sociated with a slight exacerbation.

Water.?As in the healthy posts of Nos. 5 and 4, the water supply is a mountain spring fenced in to avoid all sources of contamination : here, issuing from the spur side a little above and about ? mile from the fort. It has always been good and plentiful.* To consider this as a cause: many cases have

now come under my notice in which men direct from England or healthy parts of India, who may fairly be considered as without a trace

of malaria in their constitutions, have joined detachments during an epidemic and within six days developed ague or remittent, fever in a severe form. I had then been personally supervising the mess water in two boilings, then in its filtering through a new charcoal filter. Of this sufficient only is again boiled for tea, &c., at cliota hazri, at other times of the day Rangoon or Myingyan soda-water or German or English beer, is drunk. The (apparently) strong argument in favour of water causingmalariais the well known "Argo" case (Parke's Hygiene), where the

passengers are supposed to have drunk malari- ous water and suffered, whilst the sailors drunk

good water and escaped; but malaria was then

little understood (its incubation period may extend some times over many months), and the, to me, significant fact?as to where the passen- gers had resided, is left out. At any rate they had come from malarious districts. As regards the outbreak last year, I was not

present, but in the words of one of the medical officers who was " The fever began and ended with the rains ; every one had his dose of fever and then kept well;" certainly their sick as shewn in the Station Staff Office correspond very much with ours, though I have not the rain- fall book for 1889. Other diseases have been

conspicuous by their absence; only 16 dysentery aud 18 diarrhoea being totalled ; these are

generally classified as malarious, and in this res- pect do hill and plain malaria appear to differ.

Scurvy, in any form was hardly noticed, it was probably anticipated by the most abundant supply of fresh vegetables with plenty of goats and fowls. Lime-juice I did not use, nor do I believe in its efficacy, having seen it signally fail where a subsequent supply of vegetables and fresh meat was received and the scurvy dis-

appeared. Treatment.?Prophylaxis by quinine (2 grs.

daily to all 2-4 Gurkhas) was tried during months of June and July and then stopped, and this

brings me to the question of quinine in general for fever.

During 1887 and 1888, I had given this

drug an extended trial, and then decided in my * This I did not notice at all in the plains. f The

' unrecorded ' list comprised Burma Myook, Post

Official, Orderly Kahars, Babus, Commissariat Sergeaut, all living in various parts of the Fort, and thus the extra work was impressed on my mind.

* Six bottles were sent to Rangoon for analysis, but I

have not heard the result.

uv incAti

4-

i?t-

Dat& ^ j i | |

iV 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Hi 17 18 19 20 21 22 23 24j 25 20 [27 | 26 ! 29 .April

Dabs

IV 5 4 5 6 7 8 S 10 11 12 IS 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 20 50

UrunJalL per diem in, zruJ,

JB&i 12 15

4- _i_

Jlauy 10 14 15 16 17 18 19 20 24 25 26 28

m

-21 ?16

oaa-

03

T L. _L

4

ssasSes

to li 13

JkSt

14 15 16 17

?pea-

-taak?

18 IP 20 21 22 2S 24 25 26

Jan. 1891.] HALL ON HILL MALARIA.

own mind that its effect was almost nil, but must qualify this by adding, in and during a malarial epidemic. Here the 2-4 Gurkhas have all had quinine regularly, but the 38th B. I. none whatever. Its effect at such healthy bases as Mandalay, Myiugyan, Pokoko, Pagan, &c., dry healthy places where fever is not endemic(though cholera and diarrhoea abound) maybe explained in this way. Post hoc has been confused with Prop- ter hoc, the effect of the quinine is not the cause of the improvement, but climate has brought about the result. I had many opportunities of seeing this in 1888 and in and during malarial epidemics, doses of quinine gr. 1 carefully in- creased to grs. 120 daily* have in hundreds of

cases, in my hands, had no effect. In the few cases relatively, where patients have been re- moved to healthy parts and have, instead of improving, got worse, it has been found that

quinine was inefficacious. Some opinions of medical officers with res-

pect to remittent fever and quinine have lately been published with a verdict against it, and with respect to intermittent, I think that the natural

tendency to cure has been overlooked when qui- nine has been given. To take a supposititious case. To any given

uumber of ague cases in hospital, during an out- break, quinine is given, and to a similar number is omitted. What do we find ? Preoisely the same occurs. Some continue their agues, some stop. In a healthy climate, if the same plan be tried, the majority will stop having fever, with or with- out quinine.

I substitute a tonic mixture of Ferri et Quin. Cit. with Tr. Nucis Yom. or Ferri et Amnion. Cit. with Quinine Sulph. gr. ^?tds. (In small doses it seems an invaluable tonic). This tonic effect is, in prophylaxis probably the only.re- sult the quinine has, i.e., in obviating such pre- disposing causes to fever, which have lowered the tone of the system, e.g., anxiety, worry, over-work, diarrhoea, chills, all weakening di- seases. Antifebrin or antipyrin are moat useful to induce perspiration and to lower temperature in remittent or intermittent fever, but phenace- tine seems superior to both,and indeed to all other febrifuges, not being so depressant, though seda- tive and to be more efficacious. Complications have been few. A prolonged debility stage,owing perhaps to previous malaria at Kan with hard work during the late expedition and a want of fresh milk, was noticed. I add cod-liver oil with good result to the usual remedies. For insomnia sulphonal acts well, especially

"where symptoms such as headache and burning pains behind the eye are prominent symptoms. Iu these cases I sometimes found the head temperature (lingual) to be somewhat

higher than the body (axillary) e.g., lingual to be 99'6? and axillary 98'8?, i.e., at the same time. Though dysentery is rarely met with at Fort

White, it may not be out of place to mention here a drug that I prefer even to Ipecacuanha, viz., Hamatnelis, the preparation chiefly used

being Pond's extract of Hamamelis?dose 10 to 40 m. every hour, in 1 oz. of water day and night for an acute case. In the few dysentery cases, occurring in the later stages of remittent fever, I have here used enemata of Argnt. Nitrat. three times daily as per formula, with excellent results. R

Tr. opii ... ... ... ...m_20 Liq. Argent. Nitrat. ... ... ... 5 ss

(3) grains to 3L Mucilag. Acac. ... ... ??? 3'"

An interesting record of temperature occurred iu the case of Sergeant Lewis, Commissariat De- partment, who, after three weeks' ordinary quoii- dian ague. 011 28th August 1890, passed through li ? ? 1

the three stages of ague three times, with a

maximum temperature each tune of 104? 111 the

burning stage, and 011 29th August 1890 twice, maximum first time being 104 and second 106. Phenacetine was the only drug used, the warm stage being hastened as much as possible, shivering being severe, with well heated blankets and hot water bottles, &c. He made an excellent recovery 011 the river.

I11 conclusion, I would state that it is most

difficult, when working by oneself in a malarial epidemic to remain unprejudiced. If I have

weighed facts impartially or even succeeded in the attempt to do so, I am more than satisfied.

*

Surgeou Blaucard, has given up to grs. 200 aaily during epidemics in 1887 without result.