NationalLibraryOfScotland/medical-history-of-british-india huggingface dataset:
List of numbers of Scientific Memoirs by Officers of the Medical and Sanitary
Departments of the Government of India (New Series) published previous
to the Present issue.
No. 1. Standardisation of Calmette's anti-venomous serum with pure cobra venom : the
deterioration of this serum through keeping in India, by Captain G. Lamb,
I.M.S., and Wm. Hanna, Esq., M.B. Price As. 3 or 4d.
No. 2. Malaria in India, by Captain S. P. James, I.M.S. Price Re. 1-8 or 2s. 3d.
No. 3. Some observations on the poison of Russell's Viper (Daboia Russellii), by Captain
G. Lamb, I.M.S., and Wm. Hanna, Esq., M.B. Price As. 5 or 6 d.
No. 4. On the action of the venoms of the Cobra and of the Daboia on the red blood
corpuscles and on the blood plasma, by Captain G. Lamb, I.M.S. Price
As. 8 or 9d.
No. 5. Specificity of anti-venomous sera, by Captain G. Lamb, I.M.S. Price As. 3
or 4 d.
No. 6. First report on the anti-malarial operations in Mian Mir, 1901-03, by Captain
S. P. James, I.M.S. Price As. 12 or 1s. 2d.
No. 7. Some observations on the poison of the Banded Krait (Bungarus Fasciatus), by
Captain G. Lamb, I.M.S. Price As. 8 or 9d.
No. 8. A preliminary report on a parasite found in patients suffering from enlargement
of the spleen in India, by Lieutenant S. R. Christophers, I.M.S. Price Re. 1-8
or 2s. 3 d.
No. 9. Second report of the anti-malarial operations at Mian Mir, 1901-03, by Lieu-
tenant S. R. Christophers, I.M.S. Price As. 10 or 1s.
No. 10. Specificity of anti-venomous sera (second communication), by Captain G. Lamb,
I.M.S. Price As. 8 or 9 d.
N o . 1 1 . O n a p a r a s i t e f o u n d i n p e r s o n s s u f f e r i n g f r o m e n l a r g e m e n t o f t h e s p l e e n i n
India—Second Report, by Lieutenant S. R. Christophers, I.M.S. Price
Rs. 2 or 3s .
No. 12. On the Morphology, Teratology, and Diclinism of the flowers of Cannabis, by
Major D. Prain, I.M.S. Price As. 14 or 1 s. 4d.
No. 13. Oriental or Delhi Sore, by Captain S. P. James, I.M.S. Price As. 10 or 1s.
No. 14. On a parasite found in the white corpuscles of the blood of dogs, by Captain
S. P. J ames, I.M.S. Price As. 10 or 1s.
No. 15. On a parasite found in persons suffering from enlargement of the spleen in
India-Third Report, by Lieutenant S. R. Christophers, I.M.S.P r i c e
As. 10 or 1s.
No. 16. The specificity of anti-venomous sera with special reference to a serum prepared
with the venom of the Daboia Russellii, by Captain G. Lamb, I.M.S. Price
As. 6 or 7d.
No. 17. Snake-venoms in relation to Hæmolysis, by Captain G. Lamb, I.M.S. Price As. 6
or 7d.
No. 18. Hæmogregarina Gerbilli, by Lieutenant S. R. Christophers, M.B., I.M.S. Price
As. 10 or 1s.
No. 19. On Kala Azar, Malaria and Malarial Cachexia, by Captain S. P. James. M.B.,
I.M.S. Price Re. 1-4 or 1s. 11d.
No. 20. Serum-Therapy of Plague in India ; reports by Mr. W. M. Haffkine, C.I.E., and
various officers of the Plague Research Laboratory, Bombay, by Lieutenant--
Colonel W. B. Bannerman, M.D., B.Sc., F.R.S.E., I.M.S. P r i c e A s . 1 4 o r
1
S
. 4
d
.
2
No. 21. 0n the Standardisation of Anti-Typhoid Vaccine, by Captain George Lamb,
M.D., I.M.S. (Director, Pasteur Institute of India), and Captain W. B. C.
Forster, M.B., D.P.H., I.M.S. Price As. 6 or 7d.
No. 22. Mediterranean Fever in India: Isolation of the Micrococcus Melitensis, by Captain
George Lamb, M.D., I.M.S., and Assistant Surgeon M. Kesava Pai, M.B.,
C.M. (Madras). Price As. 10 or 1s.
No. 23. The Anatomy and Histology of Ticks, by Captain S. R. Christophers, M.B.,
I.M.S. Price Rs. 3 or 4s. 6 d.
No. 24. On a parasite found in the white corpuscles of the blood of Palm Squirrels, by
Captain W. S. Patton, M.B., I.M,S. Price As. 12 or 1 s. 2 d.
No. 25. On the importance of Larval characters in the classification of mosquitoes, by
Captain S. R. Christophers, M.B., I.M.S. Price As. 8 or 9 d.
No. 26. Leucocytozoon Canis, by Captain S. R. Christophers, M.B., I.M.S. Price
As. 12 or 1s. 2d.
No. 27. Preliminary Report on the Development of the Leishman-Donovan Body in the
Bed Bug, by Captain W. S. Patten, M.B., I.M.S. Price As. 8 or 9 d.
No. 28. The sexual cycle of Leucocytozoon Canis in the tick, by Captain S. R. Chris-
tophers, M.B., I.M.S., As. 12 or 1s. 2d.
No. 29. Piroplasma Canis and its cycle in the tick, by Captain S. R. Christophers, M.B.,
I.M.S., Price Rs. 2 or 3 s.
No. 30. The Theory and practice of Anti-Rabic immunisation, by Captain W F. Harvey,
M.B., I.M.S., and Captain Anderson McKendrick, M.B., I.M.S.,
Price Annas 12 or 1 s. 2 d
No. 31. The development of the Leishman- Donovan parasite in cimex rotundatus—Second
Report, by Captain W. S. Pâtton, M.B., I.M.S. Price Rupee 1 or 1s. 6 d.
Published by and on sale at the Office of the Superintendent of Government Printing, India, Calcutta.
Copies are also available from all Agents for the sale of Government publications.
ENTERIC FEVER IN INDIA.
A report of the enquiry carried on at the Central Research Institute.
CONTENTS .
PART I.
PAGE.
1. Introduction .
. . , . . . . . . . . .
1
2. General Summary .
.
.
.
.
.
.
.
.
. .
5
3. Observations on cases convalescent from enteric fever
.
.
.
.
.
.
7
4. Evidence in favour of epidemics of enteric fever being caused by "chronic bacilli carriers"
. 1 1
5. Evidence showing that enteric fever is contracted by orderlies whilst in attendance on cases
. 23
6. Evidence showing that orderlies on enteric fever cases become "bacilli carriers"
.
. 23
7. Diagnosis of enteric fever
.
.
.
.
.
.
.
.
.
.
.
25
8. Paratyphoid infections in India
.
.
.
.
.
.
.
.
.
2 8
9. Results of the examination of specimens of bile obtained post mortem from cases of enteric
fever .
.
.
38
10. The existence of Bacillus typhosus outside the body .
.
.
4 0
11. General conclusions
.
.
.
.
. .
'
.
.
.
.
.
47
PART II.
Appendix.
1. Table I.—Showing results obtained by daily observations on cases convalescent from enteric
fever
49
2. Table II.—Showing the results obtained by the Widal reaction and the blood culture method
in the diagnosis of enteric fever.
.
.
.
.
. .
.
.
.
1 0 6
2
illustration of the above statements. After the discovery of the causal agent of
the disease it was, until very recently, unknown where the virus is stored and
how the disease is maintained from year to year. Consequently precautions had
to be taken against every possible source of infection; the result being that
no appreciable progress was made in eradicating the disease. Finally scientific
investigation determined the storehouse of the virus—the goat ; preventive
measures were concentrated on this source and a marked reduction in the pre-
valence of the disease resulted. The case of enteric fever in India is similar.
The storehouse of the virus had not been determined by scientific investigation.
Consequently the persistence of the disease amongst the troops in the canton-
ments could not be explained. The origin of epidemics remained obscure and
was very rarely accurately determined. For the prevention of the disease
general sanitary measures were adopted, but the results were not very satis-
factory.
Such was the position of the enteric fever problem up to 1902-03, when Koch
commenced his important investigations into the etiology and mode of spread of
enteric fever. The incidence of enteric fever in Alsace-Lorraine was much
higher than in the rest of Germany ; consequently the Government requested.
Koch to conduct an investigation into the causation of the disease there.
During the course of the investigations of Koch and Frosch two very important
facts emerged—(1) that the saprophytic existence of the parasite outside the
body is very short, but (2) that it lives for prolonged periods in the body of
man after he had acquired immunity by an attack of the disease. That man, in
fact, is the storehouse of the virus, which he disseminates in nature and so
infects susceptible individuals. This was a great advance. That the observa-
tions were correct was proved by the results obtained by preventive measures con-
ducted in the light of this discovery. Enteric fever was completely eradicated
from some villages where it had been constantly present,
The conditions as regards enteric fever in Alsace-Lorraine were very
similar to those met with in Indian cantonments. Further, the results of Koch's
methods employed in his campaign against enteric were very satisfactory.
Accordingly the Government of India decided to depute Captain Greig, I.M.S.,
to proceed to Germany to study the methods on the spot.
In 1906 an enquiry into the causation of enteric fever in India was com-
menced at the Central Research Institute.
The problems to be solved were
—
1. What is the nature and duration of the saprophytic life of the Bacillus
typhosus ?
2. What is the duration of the life of the Bacillus typhosus within the
human host ?
3. How are epidemics produced ?
ENTERIC FEVER IN INDIA.
A Report of the enquiry carried on at the Central Research
Institute.
I.—INTRODUCTION.
T HE enquiry with which this report deals was commenced in April 1906 at
the Central Research Institute ; it was conducted by Lieutenant-Colonel D.
Semple, R.A.M.C. (retired), Director, Central Research Institute, and Captain.
E. D. W. Greig, I.M.S., who was placed on special duty for the purpose.
In December 1906 the services of Lieutenant-Colonel F. Wyville Thomson,
I.M.S., and in January 1907 the services of Captain D. Harvey, R.A.M.C.,
were placed at the disposal of the Government of India (Home Department) for
employment in connection with the enquiry. The services of Lieutenant-Colonel
Wyville Thomson, I.M.S., were replaced at the disposal of the Military Depart-
ment on the 3rd of September 1907. Assistant Surgeon Paras Ram, Captain
F. N. White, I.M.S., and Captain E. C. Hodgson, I.M.S., joined the Central
Research Institute to assist in the enquiry in January, August, and September,
1907, respectively.
On July 19th, 1907, Lieutenant-Colonel Semple proceeded on six months'
leave to England, and Captain E. D. W. Greig, I.M.S., was appointed officiating
Director.
In the case of enteric fever, as in the cases of Malta fever and malaria, after
the discovery of the causal agent, a considerable period elapsed before any
important fact was added to our knowledge of the disease. During this interval
preventive measures had to be of the nature of general sanitary precautions. In
attempting to carry out such measures a large amount of energy became
dissipated, because, until we have precise knowledge, it is necessary to guard.
against every conceivable source of infection. As more knowledge of disease is
acquired the most usual source of infection becomes apparent and it is possible to
concentrate attention on it, with the result that preventive measures become more
effective and cause a marked reduction in the incidence of the disease. Clearly
one of the most important questions to answer is : Where is the virus of the
disease stored in nature ? Because if this is ascertained, we are able to explain
why disease persists from month to month and year to year, and it is possible to
direct measures against this receptor of the virus and thus prevent fresh infection.
The additions to our scientific knowledge of Malta fever furnish an excellent
3
These problems were attacked along certain definite lines. We made a
number of observations on the duration of the life of the parasite outside the
human body in urine and fæces ; also in articles of clothing, etc., and we found
that under natural Indian conditions the saprophytic existence of the parasite
outside the body is remarkably short. To ascertain whether the B. typhosus
continues to live for prolonged periods inside the body of the host, we have
made observations for several months on men rendered immune by an attack
of the disease. We examined the urine and f ae ces daily. Our investigations.
have brought out the important fact that a certain percentage of these immune
men harbour the parasite and continue to do so for months and probably years.
As a rule the bacilli are not excreted daily, but at intervals, which may be very
long, sometimes as long as three months. In urine the bacillus is discharged in
enormous numbers, but in the fæces the excretion of the bacillus may persist for
a much longer time. These men show no sign of disease, and it is impossible
to determine by medical inspection whether they are free from infection or not.
In addition to those men who have become immune after a typical attack of the
disease (convalescents), we have found men, who have passed through an attack
so mild that they have not reported sick, harbouring the parasite such cases
have been observed amongst attendants on enteric fever cases (nursing orderlies).
These men return to their regiments and become sources of infection. It is
obvious, therefore, that there are scattered throughout the various units of the
British Army in India a number of men in whose bodies the virus is living.
During the course of the investigation evidence is being collected as to what
extent the natives of India harbour the parasite. Amongst the Native troops
cases have been observed. At present the incidence of enteric fever amongst
the civil population is being investigated. However, the number of foci of infec-
tion among the British troops in India is considerable and would account for a
large number of cases of enteric fever, if not for all.
As regards the production of epidemics of enteric fever in India, a scientific
study has been made of several of these and the results are fully recorded in this
report. We have been able to show conclusively that when individuals harbour-
ing the parasite have to deal with food supplies they are capable of infecting the
food and so produce epidemics. Kossel* of Giessen has recently shown that an
individual harbouring the parasite infected a milk supply and so produced a milk
epidemic. He very pertinently remarks at the end of his paper that the most
careful inspection of the dairy, its vessels, water supply, etc., will be vain if we fail
to detect an individual harbouring the parasite who is employed in the dairy.
Hence great care is necessary in selecting the personnel of dairies, cookhouses,
etc., in order to eliminate, if possible, individuals harbouring the parasite.
* Deutsche Med. Wochenschrift, No. 39, 36th September 1907 .
4
As will be readily understood from the above observations, the recognition of
individuals harbouring the parasite is of great importance. This can only be
done by a careful bacteriological examination of the blood, fæces, and urine of
the individual. The technical methods are fully discussed in a previous report
and in the present one.
Our investigations suggest the lines for the more effective control of the
disease. In the first place segregation of convalescents with careful bacterio-
logical control is essential. The bacteriological examination must be prolonged
and thorough, both urine and fæces being examined for a considerable period.
The necessity for this will be seen from a perusal of our observations recorded in
this report. At present the examination is incomplete or not carried out at
all ; therefore a number of men still harbouring the parasite are returned to duty.
This we have learned from observations made on a large number of convales-
cents. In the next place the question of attendants on enteric fever cases
requires careful consideration. For this purpose a special body of trained men
should be employed. The constant change of men from duty as enteric fever
orderlies to ordinary regimental duty as at present carried out is, as we shall see,
a means of propagating the disease. Lastly, the personnel of cookhouses,
dairies, etc., should be subject to careful bacteriological control. As will be
seen in the report, the source of two epidemics of enteric fever in India has been
scientifically proved, and in both cases the infection originated from a cook
harbouring the parasite, who infected the food and so occasioned the epidemic.
Food appears to be the most important channel of communication between the
harbourer of the parasite and the susceptible individual. This is readily under-
stood when we consider that articles of food, e.g., milk, form a favourable
medium for the development of the bacillus.
It will not be a simple matter to put into practice the measures indicated
above, but they are founded on scientific observation, and an effort should be
made to overcome the difficulties. These difficulties would be considerably
lessened by the concentration of the individuals to be examined at one or two
central stations with a laboratory suitable for undertaking the examinations
required. By such examinations, if properly carried out, individuals harbour-
ing the virus of enteric fever would be detected and the number of foci of
infection in the various units of the British Army in India would be diminished,
and so, gradually, a reduction in the incidence of the disease would be brought
about.
The literature of the subject is not dealt with in this report as a very
complete summary with references is given in the Annual Reports of the Sanitary
Commissioner with the Government of India for 1905 and 1906, to which the
reader is referred.
5
II.—GENERAL SUMMARY.
The enquiry has been carried out at Kasauli, which is a large convalescent
depôt for British troops, at Meerut in Northern India, and Poona in Southern
India. Meerut and Poona have large garrisons and enteric fever has been
prevalent in both. These three stations have afforded us opportuiities for
investigating various problems connected with enteric fever.
In this report evidence is brought forward to show
—
(I) That the bacillus typhosus continues to be excreted for long periods
in the urine and fæces of a certain percentage of patients convales-
cent from enteric fever.
(2) That the number of bacilli excreted in the urine is very large.
(3) That the excretion of the bacilli in the urine and fæces is markedly
intermittent.
(4) That the " chronic bacilli carrier" exists in different units in India and
can cause epidemics and cases of enteric fever.
(5) That enteric fever orderlies may become " chronic bacilli carriers."
(6) That enteric fever is a septicæmia from the outset of the disease and
that the most accurate method of making a diagnosis is by blood
culture.
(7) That paratyphoid fever exists in India, but the number of cases is, in
comparison with infection by B. typhosus, small. The B. para-
typhosus A. (Brion-Kayser) is a commoner cause of paratyphoid
infection than B. paratyphosus B. (Schottmüller) in India.
(8) That B. typhosus is present in the bile of cases of enteric fever in
very large numbers.
(9) That in India the saprophytic existence of the B. typhosus outside
the human host is short.
In a previous report* the various methods employed in Germany forn the
detection of B. typhosus were described. In this enquiry we have used
throughout the Drigalski Conradi medium for the detection of the B. typhosus.
In the course of our investigations we have found that better results are
obtained in the examination of fæces, if the fæces are diluted considerably
previous to plating. When the sample of fæces is received it is diluted about
20 times with sterile normal salt solution and carefully mixed in a conical
glass. The heavier material is allowed to settle to the bottom. About two or
three hours after mixing 1o r
2 c . c . o f t h e s u p e r n a t a n t f l u i d i s p l a t e d i n t h e u s u a l
manner on three large Drigalski Conradi plates. The B. typhosus was more
* Report on the methods employed in the Campaign against typhoid fever in Germany, by Captain
E. D. W. Greig, I.M.S.
6
frequently detected by this method than when a more concentrated solution of
fæces was used. For the examination of the blood we have used the bile-
glycerine-peptone medium (Conradi) and have found it very useful. This
method has greatly simplified the technique of blood culture. About 20 c.c. of
this medium is placed in a bottle (30 c.c. capacity), which is closed with a rubber
cap, sealed with paraffin. Five c.c. of blood is taken, with sterile precautions,
from a vein at the bend of elbow and at once transferred to the bile ; this is
done by simply passing the needle of the syringe through the rubber cap of the
bottle and the blood is injected into the bile, the small opening in the cap being
closed by heating the paraffin with a match. The bottle is returned to the
laboratory, and after incubation a small quantity is plated on Drigalski plates
The initial procedure can be very easily carried out in hospital and in the early
diagnosis of enteric fever cultivation gives more satisfactory results than the
Widal reaction.
It may be convenient before entering into details to summarise briefly the
results obtained during the course of the enquiry.
In elucidating the problems connected with the propagation of enteric
lever certain facts connected with the disease process require careful attention.
The results of a series of blood cultivations have shown that the typhoid bacillus.
is found in the blood stream during the first days of the disease.* In our
experience the bacillus is seldom found in the fæces at that stage and there are,
as a rule, no intestinal symptoms. It is probable that the bacillus gains an
entrance to the blood stream from one point in the alimentary tract and it is only
when it enters the blood stream that the clinical signs called enteric fever begin
to manifest themselves. The point of entry may be high up, e.g., the tonsil or
low down, below the stomach. The bacillus, as a rule, after circulating in the
blood for a time begins to deposit in some or all of the following organs ;
skin causing the rose spots ; kidneys, causing bacilluria ; liver producing infec-
tion of the bile ; the Peyer's patches leading ultimately to ulceration ; and in
other organs. From the point of view of the propagation of the disease the
most important deposits are those in the kidney, liver, and Peyer's patches, and,
probably, of these foci those in the kidneys and liver play the most important
rôle in the propagation of enteric fever. The urine and the bile become infected
from the deposits of bacilli, and as both are excellent culture media for the B.
typhosus we find bacilli present in both bile and urine, in a high percentage of
cases, in practically pure culture. In a certain number of cases the bacilli persist
in the bile or urine for months and in some cases for years after the patients
are perfectly well. The patient becomes in fact a reservoir of the parasite, which
he sheds in enormous numbers into the external world in the urine and fæces. In
*V
i d e
T a b l e I I , p a g e 1 0 7 , A p p e n d i x o f t h i s r e p o r t .