NationalLibraryOfScotland/medical-history-of-british-india huggingface dataset:
204
SANITARY REGULATIONS.
[SECT. X.
2 0 0 . A n i n v e s t i g a t i o n , s u c h a s t h e o n e c o n t e m p l a t e d , i s b e s e t w i t h
difficulty, and trustworthy results can only be arrived at slowly ; but the final
object is so important to the public interests as to afford sufficient justification
for undertaking the work.
2 0 1 .
O b j e c t o f t h e E n q u i r y .
— T h e o b j e c t o f t h i s e n q u i r y i s t o
ascertain by an investigation, as complete as our present means may enable
us to carry out, what cholera is ? What are its laws of origin and extension ?
What is the real nature of the pathological changes which occur in persons
suffering from it ? What are the best methods of treating the disease, and
by what proceedings the ravages of cholera may be mitigated, or its progress
arrested ?
2 0 2 .
E n q u i r y
i s
p r a c t i c a l .
— T h e e n q u i r y i s a p u r e l y p r a c t i c a l o n e ;
and as it may lead to legislative measures involving interference with freedom
of intercourse, and to a large expenditure of public money, as well as to con-
siderable private sacrifices, no results can be accepted for practical use unless
these are fully sustained by obvious facts.
2 0 3 . T h e e n q u i r y i s n o t t o b e u n d e r t a k e n w i t h t h e v i e w o f e s t a b l i s h i n g
any particular doctrine or hypothesis in regard to cholera, neither is it to be
carried out from any central doctrine or hypothesis, round which the facts are
expected to range themselves.
2 0 4 . I f a n y b e n e f i c i a l r e s u l t i s t o f o l l o w f r o m i t , t h e e n q u i r y m u s t b e
pursued without prepossession, and with the single object of ascertaining what
is true.
It is necessary to give this caution, on account of a natural tendency
which has shown itself in dealing with a subject of such difficulty, to trace
the manifold phenomena of epidemic cholera to some single cause, such as
epidemic influence, water contagion, cholera excreta, unhealthy subsoil,
cholera germs, and the like ; and to build on single causes, or on hypothetical
considerations, not only epidemic doctrines and pathological systems, but also
methods of treatment and measures for arresting the ravages of the disease,
at the risk of overlooking the real evils to be dealt with, and of inflicting
suffering and loss by the execution of measures not adapted to the ends they
are intended to serve.
No opinion or hypothesis, and no evidence, except such as is sufficient
to prove the existence of uniformly operating causes of disease, can ever
justify legislative action in public health questions, or the expenditure of
public funds.
2 0 5 . T h e f o l l o w i n g i n s t r u c t i o n s a r e d i r e c t e d s o l e l y t o a s c e r t a i n f a c t s ,
which, when arrived at, may indicate other points requiring examination. It is
hoped that by following rigidly and experimentally this course of proceeding,
SECT. X.]
SANITARY REGULATIONS.
205
the time may arrive when all the phenomena of cholera may arrange them-
selves naturally under some general expression indicating the measures
required for saving human life, and when the various and apparently contra-
dictory phenomena of the disease may become self-interpreting.
206. It is not intended that all Medical or other Officers should undertake
every detail in the following instructions. This course would be unadvisable,
even if it were practicable. Medical Officers will at once perceive the points
in w Lich they can render efficient aid; and it is scarcely necessary to state
that any Officer, who can communicate even a few carefully observed facts
in his locality, will do more to advance knowledge than if he were to trans-
mit conclusions or opinions founded on imperfect observations made over a
large area of country.
207. It is proposed to arrange the enquiry as follows :—
Statistical data. First. —To obtain statistics of cholera as accu-
rately as possible.
(a.) Those for the troops to be entered in detail by Regimental Surgeons
at every station, whether for British or Native troops.
(b.) Those for prisons and other public establishments by Medical Officers
attached to them.
(c.) Those for the civil population by the Sanitary Commissioner.
Movement of cholera. Second. —The facts regarding the move-
ment of cholera and the sanitary condition of troops and stations where there
are British and Native troops shall be given by the Administrative Medical
Officers of the Circle or district.
Similar facts regarding prisons and other public establishments shall be
given by the Medical Officers attached to them.
Meteorological observations should be supplied by existing Observatories,
and by the Officers at stations in charge of meteorological instruments.
Special investigations. Third.—Special microscopic, physiological,
topographical and chemical enquiries into the nature and causes of cholera
shall be conducted—
(a.) In localities where cholera is endemic,
(b.) In localities always exempt from cholera,
by officers specially set apart for these enquiries.
Chemical analyses should be conducted by practised chemists.
Fourth.—Although, for the sake of uniformity and comparison, it is
deemed advisable that special local enquiries should be undertaken by
qualified observers, Medical Officers of Military and Civil stations, prisons,
&c., are expected to undertake independent enquiries of this class to the extent
of the means at their disposal. But it is not intended that they should feel
themselves called on to do so if they have not the time or means.
206
SANITARY REGULATIONS.
[SECT. X.
Fifth. —The special enquiries will be carried out under arrangements
made by the local Government, and all reports in connection therewith
shall be sent, through the customary channels, to the Government of India
for transmission to the India Office.
208. Statistics of Cholera and Diarrhœa.—Little that is reliable
regarding epidemic diseases can be ascertained without accurate statistical
information.
209. INFORMATION REQUIRED REGARDING CIVIL POPULATION.—There is no
difficulty in obtaining information on this subject among British troops ; but
British troops constitute only a small part of the population attacked by cholera.
Epidemics seize on all classes of population, and no trustworthy information
can be obtained regarding the movement of epidemic cholera, except by
including all classes in the same general statistical inquiry.
210. CHOLERA CHART FOR TROOPS, &C.—The Statistical Chart or Register
contains the data required for British troops.* A similar Chart or Register
would answer for women and children. The same form of Register, with a
few minor alterations, is directed to be employed for Native troops and also for
the population of prisons and other establishments, where numbers of people
live together.
The data on this Register, when reduced, will give most of the infor-
mation required about the disease itself.
211. CIVIL STATISTICS OF CHOLERA.—Any statistical enquiry among the
civil population will have to be conducted on different principles, because
it is impossible to obtain all the points of comparison which are attainable
among distinct bodies of men under discipline. It is necessary, therefore,
to restrict the enquiry among the civil population to general facts showing
the course of epidemics. But this general procedure need not interfere with
special local statistical enquiries into cholera among the civil population where
it is found to be possible to carry out any such enquiries.
The following are the more important statistical points for registration by
the civil authorities in all parts of India affected by cholera, where it might
be practicable to obtain the information : —
In all statistical enquiries regarding cholera and other epidemic diseases, the
dates and localities of events are of primary importance.
I. The date of any evident increase of any class of fevers, stating the
nature of the diseases and mortality generally.
II. The date of any evident increase of bowel diseases (diarrhœa and.
dysentery), stating the disease and mortality generally.
* Registers of different sizes for different strengths of Corps are furnished to every Regi-
ment, or detachment of troops, and to all Civil and Jail Hospitals.
207
SANITARY REGULATIONS.
SECT. X.
III. Should diarrhœa or dysentery break out suddenly, so as to present
evidence of endemic attacks, the facts might be entered, wherever practicable
more in detail, as follows :—
( a. ) Date of first endemic case.
(b. ) Daily attacks and deaths. (This would include simply dates and
numbers.)
IV. A daily return of cholera attacks and deaths, wherever practicable.
A most important point in this record is the date of the first attack of
cholera and of the first death. Both should be traced carefully.
A daily return should be prepared after the date of the first attack,
unless it be impracticable to obtain the information.
If the disease has appeared among a group of population, an estimate of
the population should be entered on the return.
Where a census has been taken, more numerous and accurate data would
be available ; such as
—
The numbers and sexes alive at each age.
The daily number of attacks for each sex and each age.
The daily number of deaths for each sex and each age.
If it be impossible to obtain a daily record of cases and deaths, the return
should be limited to the following points :
—
(a.) Estimated population.
(b.) Date of first cholera case and of first death.
(c.) Date of last cholera case and of last death.
(d.) Total cholera cases and total deaths from cholera between these
dates.
212. STATISTICS OF STATION BAZAARS.—In bazaars and native towns, near
stations of British troops, arrangements are to be made by Deputy Inspectors
General in communication with Cantonment Committees, or Cantonment
Magistrates for obtaining daily statistical data regarding cholera and diarrhœa
as accurately as possible, and also for recording all endemic outbreaks of
fever, diarrhœa, or dysentery among their population.
In these circumscribed populations, where census has been taken, the
data proposed above, as to daily attacks and deaths from cholera for each sex
and age, are to be given,
The occurrence of cholera in the native population, near British troops,
should be accurately registered, to admit of comparison with the course of
the disease among the troops.
213. CHOLERA MAPS.—Tire dates of attack, and the localities, when trans-
ferred to station, town, or bazaar plans, and to maps for the whole country,
208
SANITARY REGULATIONS.
[SECT. X.
will afford information as to the laws of progress of cholera, such as can be
obtained in no other way.
214. Meteorology.—If meteorological observations are accurately kept,
according to the instructions, at stations which have been provided with
instruments, a comparison of the data over a series of years, including epidemic
years, will afford all the required information in this department of the
subject.
In comparing the meteorological elements of epidemic and non-epidemic
years, for reports, the elements of most importance are—
(a.) Barometric pressure above the average.
(b.) Unusual droughts leading to diminution and contamination of
the water-supply.
( c .
) U n u s u a l r a i n - f a l l s l e a d i n g t o d e v e l o p m e n t o f l o c a l m a l a r i a , o r
other local causes of disease or unexpected rain-falls resulting in
wearing of wet clothing.
(d.) Rapid changes of temperature, especially at unaccustomed times,
leading to diminished or checked cutaneous action.
( e .
) U n u s u a l l y h i g h t e m p e r a t u r e s c o m b i n e d w i t h r a i n - f a l l s .
( f .
) D i r e c t i o n a n d . s t r e n g t h o f w i n d s . I t h a s b e e n s t a t e d t h a t w i n d s
coming from particular points have been accompanied by increase
of cholera attacks, or that cholera has progressed in the direction,
or against the direction of prevailing winds. All these points
should be carefully noted.
( g .
) S t i l l n e s s o f a t m o s p h e r e , i n d i c a t i n g s t a g n a t i o n i n c i t i e s , v i l l a g e s ,
or dwelling-houses, as well as diminution of oxygenating power
of the air.
(h. ) Amount of ozone. Prevalence, or otherwise of fogs. Excess, or
diminution of hygrometric state of the air. Peculiarities in elec-
tric condition of the air.
( i .) Unusual atmospheric phenomena preceding the appearance or
disappearance of cholera should be noted.
215. Movement of Cholera.—Observations on the movement of
cholera must necessarily be conducted by observers in numerous localities
before the law of movement can be arrived at. But the scientific facts can
be ascertained at a few selected stations.
216. POINTS FOR OBSERVAVION.—The following are the points in regard
to which systematic observations on the movement of cholera are necessary
among British and Native troops, as well as among the population gene-
rally.
SECT. X.]
SANITARY REGULATIONS.
209'
217. PREMONITIONS OF CHOLERA.—When cholera is approaching a district,
are there any indications of an altered state of health among the unaffected;
inhabitants, such as disturbance of the digestive organs, altered expression
of countenance, or of colour of the conjuntivæ and other mucous membranes ;
or of the skin, in Europeans and light-skinned native races ?
218. PREVALENCE OF OTHER DISEASES.—Are diarrhœal or dysenteric affec-
tions, or fevers, more than usually prevalent ?
Are there any other premonitions of cholera observable ?
Positive or negative replies on these points should be given.
219. Forms of Cholera. —Cholera presents itself under three states or
forms :—
1 . T h e s p o r a d i c f o r m .
2 . T h e e n d e m i c f o r m .
3 . T h e e p i d e m i c f o r m .
In regard to these three forms of the disease, the following questions
suggest themselves :—
(a.) Are they precisely similar, or in what respects do they differ in their
observed. characters ?
(b.) Do premonitory symptoms prevail among unaffected persons in loca-
lities, where each of the three forms occur ?
(c.) Are there any appreciable phenomena in the disease, in the locality,
in the habits of the people, or in the nature of the seasons and atmospheric
conditions, which would obviously account for the existence of one form
rather than another, or for the passage of one form into another ?
(d.) Are there any facts to show why a sporadic case of cholera is not
followed by other cases ? Or,
Why an endemic outbreak does not become epidemic ?
220. QUESTION OF SUSCEPTIBILITY .—During endemic outbreaks, as well as
during epidemics of cholera, it is usually observed that of the population
exposed apparently to precisely similar conditions, a portion only suffer from
the developed form of the disease, while the majority usually escape, or suffer
from comparatively trivial symptoms.
221. It has hence been the custom to divide a population exposed to the same
causes of diseases into two classes : " susceptible," those who have suffered ;
and " non-susceptible," those who have escaped. But it is obvious that such
a division affords no explanation of the occurrence. It merely repeats in
other words the obvious fact that some have suffered while others have
escaped. An attempt should be made towards an explanation of differences in
susceptibility by obtaining replies to the following questions. But any other
points, calculated to throw light on the question of susceptibility, should be
stated.
B B
210
SANITARY REGULATTONS.
[SECT. X.
222. INFLUENCE OF SEX AND AGE.—Of persons living in a circumscribed
endemic locality, the numbers of whom at each age and of each sex have been
ascertained by census; what percentage of each sex and each age living is
usually attacked by cholera ?
223. INFLUENCE OF TEMPERAMENT.—Does cholera take place equally in all
temperaments, or do certain temperaments suffer more than others ?
224: INFLUENCE OF DIET.—Is there any observed difference in the per-
centages of attacks among persons who live mainly on vegetable diet, as
compared with the per-centages among persons who live on mixed. diet ?
225. INFLUENCE OF HEALTH AND HABIT OF BODY.—Has the occurrence of
cholera among a population any marked relation to a state of general health
or habit of body among those who suffer which does not exist amongst these
who escape ?
226. INFLUENCE OF RACE.—Is there any appreciable difference in the
liability to attacks, or in the proportionate mortality from cholera among
different races in India ?
226.
227. INFLUENCE OF OCCUPATION.—Are any trades or occupations observed
to be more conducive to attacks of cholera than others ?
(a.). Can it be shown by statistics whether mehters employed in collect-
ing and removing excreta during times when cholera prevails suffer more
from cholera, or only to the same extent as others living in similar localities ?
( b.). Are occupations involving much fatigue, or long marches, and the
like, more or less conducive to cholera ?
228. INFLUENCE OF INTEMPERANCE .—Has the use of spirituous liquors any
apparent influence on susceptibility to cholera ?
229. INFLUENCE OF TEMPERANCE.—Have regular temperate habits of life
any apparent influence on susceptibility to cholera ?
230. INFLUENCE OF THE ELEMENT OF NUMBER.—Can the exact influence of
aggregations of persons, both as regards—
(a ) Actual numbers,
(b. ) Crowding on a given area,
on susceptibility to cholera be proved statistically ?
231. Communicability of cholera. —The fact, whether or not cholera
is communicable, directly or indirectly, from person to person, should be posi-
tively ascertained.
232. SOURCES OF EVI DENCE. —Ev i d e n c e , e i t h e r p o s i t i v e o r n e g a t i v e , o n
this most important subject, may be derived from two sources, experiment
and observation.
233. EXPERIMENTAL EVIDENCE.— The class of experiments, most likely to
prove or disprove communicability, will be undertaken by officers specially
selected to report on this branch of the enquiry.
SECT. X.] SANITARY REGULATIONS. 211
234. EVIDENCE FROM OBSERVATIONS OF SPORADIC CHOLERA.—If a solitary
indigenous case of sporadic cholera presents itself, the following questions
will arise :—
(a.) What was the origin of the case ?
(b.) Is there or is there not evidence to show that infection was
imported from some distant place where cholera prevailed?
(c.) If there is evidence of importation, every step in the proof should
be very carefully investigated and given in detail.
(d.) If the case had no communication with any other case, this fact
should be stated.
(e.) The results, whatever they may be, of every enquiry made into the
foreign origin of sporadic cases, should be recorded.
(f.) Were there any local, personal, or atmospheric conditions to which
the occurrence of the sporadic case might be reasonably attributed ?
(g.) Was the communication which existed between the sporadic case
and other inmates of the house, or between these inmates and those in
other houses, followed by any appreciable effect on health ?
235. EVIDENCE FROM OBSERVATIONS OF ENDEMIC CHOLERA..—When an
endemic outbreak of cholera takes place, similar questions would arise, as
follows :—
(a.) Was there any communication between the seat of the outbreak
and any other locality where cholera previously prevailed ?
(b.) If so, the dates and other evidence should be carefully given,
and the precise nature of the communication should be described.
(c.) Could the progress of the endemic attack be distinctly traced to
communication between the first or earlier endemic cases in the same locality
and persons subsequently attacked? If so, state in detail the nature of the
communication with the dates.
(d. ) To complete the evidence on the subject of communication, it
should. be distinctly stated, whether, or not there was communication between
affected and unaffected persons without extension of the disease.
236. EVIDENCE FROM OBSERVATION OF CHOLERA IN PRISONS.—Prisons afford
excellent opportunities of investigating questions regarding cholera, including
development of the disease, its relation to personal communication, or to
purely local causes, its relation to endemic outbreaks in districts where prisons
are situated, and to any general epidemic movement of the disease.
By observations made in prisons and prison infirmaries, we might
ascertain whether cholera is preceded by appreciable changes in the health.
of prisoners ; whether the disease breaks out without visible communication
of any kind with affected districts ; the laws of its development and extension
212
SANITARY REGULATIONS.
[SECT. X.
among prison populations. Instances in which it appeared in different parts of
the prison, without communication with affected prisoners, should be noted.
As also the number of instances in which it did not appear after communica-
tion between affected and unaffected prisoners. Care might be taken to
prevent all communication temporarily between affected districts or parts of
the prison., and unaffected prisoners, with the view of ascertaining whether
the disease could be kept out of the prison, or confined to that part of the
prison first affected.
A large number of observations of this class are required before
conclusions can be drawn from them.
237. EVIDENCE FROM OBSERVATIONS OF EPIDEMIC CHOLERA.—When cholera
takes on the epidemic form, it will become necessary to investigate very care-
fully the relation of movements of the population to movements of cholera.
With this view the following steps should be taken :—
(a.) A record of all groups of population, cities, villages, and the like,
in the region of the epidemic, should be made.
(b.) On this record the localities successively attacked from the first
appearance of epidemic onwards to its termination, with dates of attack and
other particulars, should be entered.
(c.) The localities and dates of unusual outbreaks of other diseases of
the epidemic class, fevers, diarrhœa, dysentery, if there have been any such,
should be recorded.
238. These data are necessary, in order to show the exact number of
groups of population which suffered or escaped within the epidemic region,
and also to show whether cholera was or was not present before the arrival
of persons, pilgrims, and others from affected districts.
239. MEANS OF COMMUNICATION TO BE DESCRIBED . —In describing the
movements of population between affected and unaffected districts, the means
of communication, whether by walking, carriage, steamers, boats, railways,
together with the rate of travelling, should be stated.
240. Importance of observing the influence of Railway commu-
nication during epidemies.—Where the exact places, dates, and times of
arrival can be ascertained, as in the case of railways, very important facts
can be obtained with little difficulty.
241. NATURE OF DATA.—The following data for lines of railway would
go far to show what is really the relation between movement of population
and movement of cholera. Similar data might be obtained for main lines
highway and steam-boats :
—
( a. ) Names of stations and times of departure and arrival along the
line of railway.