Diseases and Epidemics

The first important Arabic medical treatise that elaborately discussed and summarized the Indian system of medicine of this age is Firdaus-al-Hikmat, by Ali ibn Sahl Rabban al-Tabari, who died about A.D. 855.

The work of Rhazes, written in this period, deals systematically with head, eye, lungs, and digestive and circulatory systems, along with diseases of women and midwifery. The contents of the author's studies demonstrate his competence and skill in recognizing various diseases, in differentiating similar diseases symptomatically, in making their classifications, and in adopting methods to treat them.

Appearing early in the eleventh century, Al-Qanun fi, al-Tibb by Avicenna is by far the largest and most famous medical work of this period. The work is divided into five major books. The first book treats general principles; the second treats simple drugs arranged alphabetically; the third deals with diseases of particular organs and members of the body from head to toe; the fourth deals with diseases that, though local and partial in their inception, tend to spread to other parts of the body; and the fifth deals with compound medicines.

The Madanul-Shifa i-Sikandar Shahi (Sikandar Shah's Mine of Medicine), written in 1512 by Mian Bhowa, discusses the symptoms and treatments of many diseases, including fevers, diarrhea, whooping cough, dropsy, epilepsy, rheumatism, erysipelas, heart diseases, gonorrhea, scrofula, elephantiasis, leprosy, smallpox, measles, and afflictions of children. In all, it discusses 1,167 diseases and the effects of various medicaments.

Smallpox

Inoculation for smallpox seems to have been known to the Hindus from a very early age. Long before Edward Jenner, certain classes in India, especially cow herders, shepherds, charans, and the like, had been in the habit of collecting and preserving the dry scabs of the pustules. They would place a little of this material on the forearm, and puncture the skin with a needle. As a result of this inoculation, these classes are purported to have enjoyed a certain amount of immunity from the disease.

In India, temples in which a deity of smallpox was worshipped hint at its presence prior to 1160 B.C. In ancient India, smallpox was, therefore, apparently regarded by the Hindus as a manifestation of a Hindu goddess called Maria-tal, Mari-amma Devi, Mata, or Sitala. According to W. A. Jayne (1979), "Sitala (the 'Cool-Lady' with a euphemistic allusion to the burning fever) was small-pox." The goddess was worshipped regularly so that she would not circulate among the villages. One could probably find shrines to her in any village or town in ancient India, according to O. P. Jaggi (1980).

So it seems that the Indian civilization has faced smallpox epidemics on numerous occasions, yet details regarding the complete history of the illness in South Asia remain obscure. The first clinical account of the disease appears in the Middle Ages, by the most competent physician of his age, Rhazes. Although brief mention of smallpox is made in two medical treatises of the period, the work of Rhazes is the first in which the illness is fully treated and in which its symptoms are described. Bhowa's medical treatise appearing in 1512 mentioned the disease smallpox-measles, along with its treatment. Around 1700, Hakim Mohammed Akbar bin Mohammad Muqin Arzani wrote Mufarreh ul-Qulub, in which he recorded his own experiments with treatments he adopted to relive the burning and throbbing sensation of the vesicles of smallpox.

The disease attacked the rich and the poor alike. A

civil surgeon of Dacca, for example, found that in the history of the Tipperah family, between the fifteenth and eighteenth centuries, 5 out of 16 Maharajahs died from smallpox. According to S. P. James (1909), an observer writing in 1767 about the prevalence of smallpox in Bengal, said:

Every seventh year with scarcely any exception, the small-pox rages epidemically in these provinces during the months of March, April and May, until the annual returning rains about the middle of June put a stop to its fury. On these periodical returns, the disease proves universally of the most malignant confluent kind, from which few either of the Indians or the Europeans escaped that took the distemper in the natural way, commonly dying on the first, second or third day of eruption.

Inoculation against smallpox has been practiced in the subcontinent since ancient times, and accounts of the procedure are available in the writings of several British writers. O. Coult has given an account of smallpox inoculation (tikah) as he observed it in Bengal in the year 1731. Edward Ives, who was a naval surgeon on the flagship Kent and who was in India in 1754-7, has given further details of the method. In Calcutta inoculation was practiced among certain classes of Europeans as early as 1785, and apparently in 1787 the government established a hospital for smallpox inoculation at Dum Dum. In 1798, after much experimentation, Edward Jenner established that prior cowpox inoculation (i.e., vaccination; the Latin word for "cow" being Vacca and for "cowpox," Vaccinia) protected the person from getting smallpox, even though he or she was exposed to it. The practice of vaccination was accepted quickly in England, western Europe, and Russia, and by 1802, only 4 years after this discovery, vaccination was introduced in India.

Cholera

The history of cholera began on the subcontinent of India. Both literary records and religious practices suggest that cholera was endemic to the South Asian region for at least 2,000 years, but it was not until the sixteenth century that European travelers, explorers, traders, and officials provided detailed descriptions of a terrible plague whose symptoms were those of cholera and which was reported to reach epidemic proportions. One authority has identified 64 separate accounts of cholera in India between 1503 and 1817, and no less than 10 of those refer specifically to epidemics. The areas of cholera's historic endemicity were in South Asia, and especially in the delta regions of east and west Bengal.

It is said that the first pandemic of the early nineteenth century remained geographically in Asia, though it approached Europe, and it may have touched Africa at Zanzibar. The following second, third, and fourth pandemics affected the entire world, though with considerable regional variations; the areas of incidence receded significantly in the fifth and sixth pandemics.

During the medieval period, court chronicles described the occurrence of pestilences, though it is difficult to identify their correct nature in terms of diseases we now recognize. G. Gaskoin (1867) refers to Lendas da India, a publication by a Portuguese named Gaspar Correia, who in the spring of 1543 witnessed cholera in an epidemic form at Goa. The local people called it moryxy, and the mortality was so great that burying the dead was difficult. In 1563, Garcia da Orta wrote a vivid description of cholera as he saw it at Goa, adding that the disease was most severe in June and July. In the 1600s, more reports of epidemic cholera appeared in Madura (1609), Jakarta (1629), and Goa (1683). Cholera was next reported in 1783, when it broke out at Hardwar and, in less than 8 days, killed approximately 20,000 pilgrims. At the same time, the Maratha armies, engaged in war with Tipu Sultan (the Sultan of Mysore), suffered severely from the disease. In 1787, there was another account of the disease in India given by an English physician (a Dr. Paisley). Again in 1796, Fra Paolino de S. Bartolomeo penned an account of cholera in India.

The appearance of the disease at Fort William in 1814 was reported by R. Tytler, Civil Surgeon of Jessore. However, the first full and accurate account of epidemic cholera dates from 1817 to 1823. The earliest notice of this epidemic was given by Tytler in a letter dated August 1817: "An epidemic has broke out in the bazaars, the disorder commencing with pain or uneasiness in different parts of the body, presently succeeded by giddiness of the head, sickness, vomiting, griping in the belly and frequent stools."

While the cholera epidemic spread in the countries to the west of India, it was also transported to the east. In 1819, Burma and Ceylon were under its influence. The next year Siam was afflicted, as was Malacca, where the disease was said to have been brought by a vessel from the coast. Shortly after some persons with cholera-like symptoms landed from a vessel, the outbreak began. This outbreak occurred after Dutch vessels coming from Calcutta had anchored at Malacca. China and the islands of the Mauritius were also overwhelmed by the disease.

The cholera epidemic of 1817-23 gradually disappeared from the countries over which it had spread, and in Bengal little was heard of the disease throughout the years 1823-5, except in the endemic areas. But during the first quarter of 1826, cholera again erupted throughout the lower Bengal. From there it spread to Banaras and extended as far as the Kan-pur Division, reaching the stations on the right bank of the Jamna. It was heard of at Hardwar in April and throughout the northwestern frontier provinces and along the Himalayas before the middle of June. Bombay Presidency, Sind, and the Punjab were assaulted by the disease which reached there from the east during the year 1827. It entered Khiva and Herat via Kabul in 1829. The epidemic from Kabul, Herat, and Persia spread to Russia and Poland in 1830, to England in 1821-32, to France in 1832, and in the same year to America, where it made its first appearance, to Cuba and Mexico in 1833, again to Europe from 1835-7, and finally to Africa in 1837. Subsequent cholera epidemics were observed in Europe and America (1848-53), in Punjab (1855), in Persia (1857), and in Arabia (1858-9). It appeared again in Punjab (1861), and traveled from Bengal to Africa, Arabia, Europe, and America (1863-5).

Plague

There is uncertainty in attempting to trace the historical background of plague in South Asian territories. According to Jaggi, extant references in Indian history for some pestilences that raged from time to time could indicate epidemics of plague. One probable epidemic attacked the army of Muhammad Tughlaq in the twelfth century. Again in the year 1443, a pestilence caused great loss of life in the army of Sultan Ahmad I. Farishta, a contemporary of the Mogul emperor Akbar, mentioned the occurrence of a fatal epidemic similar to that of bubonic plague in Bihar in 1548. A very devastating plague-like pestilence raged in Gaur, the medieval capital of Bengal, in 1573. The great famine of 1590 was followed by a severe epidemic, which may or may not have been plague. Tuzuk-i-Jahangiri described the occurrence of plague near Agra in 1618.

The Gujarat plague epidemic of 1812-61 was the first in India for which a detailed account is available. It broke out in 1812 in Kutch and is said to have destroyed half of the population before spreading to Kathiawar and Gujarat. According to a statement given by D. V. Gilder in the Indian Medical Gazette near the turn of the century (Nathan 1898):

In tracing the origin of disease in question the natives agree in referring the period of its first introduction to the

Hindoo year or Sumwat 1873 (A.D. 1817) three years subsequent to the dreadful famine, which raged with such destructive fury over Gujarat and Kathiawar. The disease extended to several other areas such as Kutch, Dholera, Peeplee, and Limree, etc., and people roughly distinguished it by the term Ghaut no roque possessing the following symptoms: great and general uneasiness of the frame, pains in the head, lumbar region and joints on the day of attack, hard, knotty and highly painful swellings of the inguinal or axillary glands (whence the name appears) in some instances; the parotids are affected in 4 or 5 hours, fever supervenes; these symptoms go on increasing in violence, attended with great thirst and delirium until the third day of the attack, when death closes the scene.

Another British physician also gave an interesting account of disease spread from Kathiawar, according to R. Nathan (1898):

In 1813 the plague was present in Central India and Raj-putana, Kutch and Kathiawar and was first noticed at Kumtakale, and spread throughout Wagar during January, February and March 1816, and by the end of that year had extended to Sunde where the mortality was great. The disease was still prevalent in Central India in 1819, and disappeared in 1821. Nothing more was heard of the disease in Central India till July 1836, when it broke out at Pali, a town of Marwar, whence it spread to Jodhpur. It prevailed at Deoghur, in Meywar, in March 1837, and thereafter extended to Jalia and Ramghat in the district of Ajmere. The disease disappeared toward the end of 1837, but in November of that year, it again broke out in epidemic form at Pali, and continued till February the following year.

The same physician also wrote of mahamari (gola or phutkiya rog), an endemic disease of Kumaun and Garhwal in the Himalayas. The first record of the disease is dated 1823 at Kedarnath, Garhwal. From 1834, outbreaks in these districts occurred every few years, except for a long interval between 1860 and 1875, when it appeared to remain quiescent. After 1878, the outbreaks were not severe. The disease descended to the plains in 1853. In that year it appeared in an epidemic form in towns in the district Moradabad. According to Nathan (1898), a physician there concluded that mahamari was identical with the uncomplicated form of glandular plague of Egypt and that it could be conveyed by contagion and spread by endemic causes such as filth, poverty, and unclean habits of the inhabitants. In 1875, the disease was prevalent in certain villages in Kumaun where C. Planck (Jaggi 1980) recorded about 277 deaths and confirmed the opinion that it was the pestis or plague in medical terminology; he also recorded the first local history of mahamari in 40 vil lages attacked. This disease continued to be reported in the surrounding regions until 1893.

In 1896 plague broke out in Bombay, and its diagnosis was confirmed by W. M. Haffkine (Nathan 1898) in October of that year. The mortality rate in Jains at that time was significant, reaching a peak of over 100,000 persons. A Plague Research Commission was formed in Bombay in 1905, which worked under an advisory committee that was constituted in India and included representation of the Royal Society, the Lister Institute, and the India Office. This commission continued to work until 1913, and their studies have formed the basis of our present knowledge of the epidemiology of bubonic plague.

Malaria

Malaria is a parasitic disease that probably tormented primates long before humankind walked the Earth. The Indian art and medical classics make it clear that malaria had a long history on the subcontinent area, a history that has been illuminated at various points in the classical medical texts of ancient Hindu medicine. Susruta established a vague relationship between malaria and mosquito bites. This mythical savant classified the relevant types of fevers, and linked these with specific types of mosquitoes. As in Egypt and Mesopotamia, in the tropical dampness of the Indian river valleys, malaria reaped a deadly harvest, as it had probably done for millennia (1.4 million deaths in British India in 1939 alone) (Thorwald 1963).

The existence of a great many diseases in ancient South Asia is reflected in the Vedic books. As might be expected, fevers predominate because India is still probably the most malarial country on Earth, as well as the breeding ground for plague and cholera. But no clear statistics on the early history of malaria are available.

The nineteenth-century British medical statistics give some clear indications of the intensity of the infection. In Bengal, Bombay, and Madras, over the periods 1847-54 and 1860-75, of 1,110,820 British soldiers, 457,088 (or 41.1 percent) were reported as malarial cases (McGrew and McGrew 1985). Two other nineteenth-century investigations are worthy of mention: (1) In 1845, a surgeon major introduced the spleen rate as a measure of malarial endemicity and used it to map out the incidence of malaria in villages in the Punjab lying along the course of the old Jammu canal. (2) A great advance in malaria therapy was made in 1877 when a method of manufacturing pure quinine sulfate was discovered at the government's Sikkim plantation, which resulted in a great reduction in the cost of quinine production all over the world.

Kala-Azar or Visceral Leishmaniasis In India kala-azar has been recognized as a distinct clinical entity for over 150 years. A number of epidemics occurred in Bengal in the mid-nineteenth century, and, although it was undoubtedly confused with malaria, the high treatment failure and mortality rates made the physicians of those days realize that they were dealing with a different illness. More attention was paid to the disease when in 1875 it began to invade Assam; kala-azar swept up the Brahmaputra Valley in three distinct epidemic waves between 1875 and 1917. The nature of the disease was clarified in 1903 when the causal organism now classified as Leishmania donovani was discovered by William Leishman in the spleen of a soldier who died in England from kala-azar, which he had contracted at Dum Dum, a military post just outside Calcutta.

Cutaneous leishmaniasis - or "oriental sore" or Delhi boil - is prevalent in the northern and western parts of India, especially in the United Provinces and the Punjab. It is caused by Leishmania tropica, which is transmitted by Phlebotomus papatasii in the subcontinent.

Other Diseases

Typhoid, influenza, dysentery, hepatitis, tuberculosis, as well as illnesses associated with malnutrition, are comparatively new diseases in South Asia in the sense that they are newly identified. However, leprosy and the venereal diseases are quite old, and ancient Vedic texts include descriptions of these diseases although they are not well sorted out from other diseases of the same classes.

Hakim Mohammed Said

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