NationalLibraryOfScotland/medical-history-of-british-india huggingface dataset:
( 80 )
(5) the examination of the blood of every one in the jail community
and the segregation and institution of treatment of all those in
whose blood malaria parasites were found would be carried out
monthly.
By these means an attempt would be made to kill off the malaria
parasites in the blood of all human malaria-carriers within and in the
vicinity of the jail, so that Anopheline mosquitoes could no longer become
infected and the disease would die out.
B.—The prevention of malarial fevers by the use of quinine.
One difference between the plan for the eradication of malaria by the
use of quinine and that for the prevention of malaria by the use of quinine
is that in the former only a few of the inhabitants (namely, those in whose
blood malaria parasites are found) are treated with quinine, while in the
latter every one must take quinine. Another difference is that blood
examinations must be carried out in the former, but are not necessary in
the latter.
The taking of quinine is an empirical method of preventing malarial
fevers which was known to be of great service long before the discovery of
the way in which the disease is spread, and in places where more scientific
measures cannot be applied or have not been successful it is still largely
used. The three chief plans of using quinine as a prophylactic are :—
The preven-
tion of
malaria
by the use of
quinine.
(1) A dose of 15 grams of quinine is given on each of two successive
days every eight days throughout the epidemic period. This is
sometimes called the method of Dr. Koch.
(2) A dose of 4 grains of quinine is given daily throughout the epidemic
period. This is sometimes called the method of Dr. Celli.
(3) A dose of 15 grains is given once a week.
Those who advocate Dr. Celli's method state that by daily administra-
tion there is produced an accumulation of the alkaloid in the blood, that
the phenomena of cinchonism are obviated, and that the curative effect of
large doses does not suffer diminution from the system being habituated to
smaller ones. But the small doses have no notable effect upon relapses,
which doubtless comprise a considerable proportion of the cases of malarial
fever met with in Indian hospitals and jails.
( 81 )
The plan of giving only one dose of 15 grains once a week merits further
trial, as it is obvious that the best plan of dosage is that which effects the
desired result with the least expenditure of quinine and at the least cost of
time and trouble.
Good results have been reported from the use of each of the methods, and
it is the duty of the officer in charge of the persons who are to be treated
prophylactically to choose one of the plans, having regard to local circum
stances and to the degree of control which can be exercised during the prepara-
tion and administration of the prophylactic doses, and to abide by it. The
decision having been made, the next consideration will be the administrative
details connected with the proper carrying out of the measure. The dates
between which the method will be undertaken will be decided' and then the
details of the procedure to be followed. Printed forms may be used in which
these details can be entered each time the prophylactic doses are given. The
forms might contain the following headings :—
Name of Jail or Institution.
Date of administration of the prophylactic.
Number of persons to whom the prophylactic was administered.
Drug and dose in grains.
Form in which the drug was administered.
Name of the person who made up the prescription. What precautions were
taken to ensure that it was correctly dispensed ?
Name of the person who administered the prophylactic. What precautions
were taken to ensure that it was correctly administered to all for
whom it was intended ?
General remarks.
It must always be borne in mind that the results obtained in the preven-
tion of malarial fevers by the use of quinine are dependent entirely upon the
degree of supervision exercised during the preparation and during the adminis-
tration of the doses, and that in institutions where this method of prophylaxis
is adopted the prevalence of malarial fevers among the inmates is one measure
of the care and capacity with which the duties of management are performed.
In order to illustrate the minute attention to details which is essential
for obtaining successful results in prophylaxis by the use of quinine the
G
( 82 )
following account may be given of the procedure adopted in a jail where this
measure was attended with excellent results.* The dose selected was 15
grains to be given in a single dose every Monday morning at the time when
the prisoners were drawn up for the weekly parade. The articles used in con-
nexion with the measure were (1) quinine sulphate in powder ; (2) dilute
sulphuric acid ; (3) water ; (4) a pair of scales and weights ; (5) a large vessel
or jar having a wide mouth provided with a lid which could be sealed up ;
(6) a long-handled wooden ladle holding exactly one ounce; (7) small glass
tumblers, one for each person who was to take the prophylactic dose. These
tumblers were obtained in the local bazaar and were of different colours ; plain
white ones were used for Hindus, green ones for Mahomedans, and brown
ones for others.
Every Monday morning at the time when the office work of the jail was
being done the compounder was required to bring the quinine, the acid, the
water, the scales and the large jar into the office. The calculation of the
amount of quinine which would be necessary for the number of prisoners on
parade, the weighing out of the quinine, the addition of water and acid in
such amount that one ounce of the mixture would be a dose, and the
transference of the mixture to the large jar were then carried out under the
Medical Officer's supervision. Then the lid of the jar was sealed. At the
parade, which was held just before the morning meal, the tumblers were
distributed and the jar opened. The prisoners were divided into small
parties or squads, and at a word of command each prisoner in the squad
held his tumbler at arm's length in front of him. The vessel containing the
mixture being carried by one man and the long -handled ladle by another, the
Medical Officer and these men then passed down the line, a dose of the
mixture being ladled out into each man's glass on the way. Each prisoner in
the squad was required to keep his tumbler at arm's length, until the distribu-
tion of the doses to all men in the squad was completed. Then at a word of com-
mand all drank the dose, and immediately afterwards the Medical Officer passed
along the line again for the purpose of examining each man's teeth and
gums (for signs of scurvy, etc.) and of ascertaining that the dose had been
swallowed.
* The procedure was devised by Major R. Heard, I.M.S.
( 83 )
A dose of 15 grains of quinine dissolved in only one ounce of water is
an extremely bitter draught, and it has been recommended by Lieute-
nant-Colonel Buchanan, I.M.S., Inspector General of Prisons in Bengal, that
the dose should be dissolved in three or four ounces of water. The
dilution of the quinine in this way not only makes the draught less unplea-
sant and less liable to be vomited, but is said to prevent to a considerable
extent the symptoms of cinchonism which are brought on in some people by
the comparatively large dose of the drug. Medical officers in India whose
experience of this method of preventing malaria is very extensive have found
also that although in institutions a large number of cases of cinchonism occur
when the measure is commenced, if it is persevered with the number of cases
quickly becomes extremely few. Finally it must not be supposed that the
method of carrying out the measure which has been described above is the
only good one ; different, but equally good, methods are in use in many
Indian jails.
II.—Methods in which quinine is not used.
These methods are based on the knowledge that Anopheline mosquitoes
are the carriers of malaria and that people with malaria parasites in their
blood are the source from which Anopheline mosquitoes become infected and
able to carry the disease
The methods are —
(1) The extermination of Anopheline mosquitoes.
(2) The protection of every one from the bites of Anopheline mos-
quitoes.
(3) " Segregation. "
The plan of attempting to exterminate or to reduce the number of Ano-
pheline mosquitoes in malarious districts was initiated by Major Ronald Ross,
I.M.S., the discoverer of the facts upon which all modern systems of pro-
phylaxis are based. This method may, therefore, be called the method of
Ross.
The plan of attempting to protect every one from the bites of infected
Anopheline mosquitoes, by covering in the doors and windows of houses with
G 2
( 84 )
mosquito-proof netting has been chiefly advocated by Professor Celli in Italy,
and it may, therefore, be appropriately called the method of Celli.
The third plan, that of segregation, differs from segregation measures
usually carried out in the case of other contagious diseases, in that it has
for its object not thy segregation of the sick but of the healthy. It
has been chiefly advocated for the protection of Europeans who are obliged to
live in malarious districts, and it has its foundation in the fact that natives,
and especially native children, in malarious countries form the chief source
of infection of Anopheline mosquitoes. It assumes also that such mosquitoes
do not habitually fly more than half a mile, and that they bite at night-time
only. On these grounds it is advocated that no European house should be
built within half a mile of a malarious town or village, and that no native
servants or their children should be allowed to sleep at night in the com-
pounds of European bungalows, but that their quarters should be placed as
far as possible from the bungalow.
This method of prophylaxis goes by the name of " The segregation of
Europeans," and was initiated by Drs. Stephens and Christophers, who con-
sider it to be the most efficient way of protecting Europeans from malaria
in certain parts of Africa and India.
Having thus briefly summarised the different methods of prophylaxis
recommended, we may now apply our knowledge to the following particular
cases :—
(1) Prophylaxis as applied to the individual.
(2) Prophylaxis as applied to any particular body of individuals such
as a regiment of soldiers or the inmates of a jail.
(3) Prophylaxis as applied to communities.
1. Prophylaxis for the individual.—In considering the prevention of
malarial fevers from the point of view of the individual it is necessary to
distinguish carefully between two points which are frequently confused,
viz. : (1) the prevention of first or new infections; and (2) the prevention of
relapses of former attacks.
There is no doubt that any individual, who wishes to do so, may effec-
tually protect himself from a first or a new infection, wherever he may be
( 85 )
living, by taking measures to prevent himself from being bitten by mosquitoes.
This has been proved, and at the present time is not doubted by any one
who is capable of forming an impartial opinion on the matter.
The chief precautions to be taken are :—
(1) Never go to sleep except under a good mosquito curtain.
(2) Never go out in the evening or sit in the house or verandah without
wearing sufficient clothes to protect the whole body from
mosquito bites.
Especial care should be taken to protect the feet and ankles by wearing
high boots or putties. The reason for this precaution will be obvious
to anyone who has lived in the tropics. Theoretically it would also be
necessary to protect the hands by wearing gloves and the race and
head by wearing a gauze net covering; but in actual practice it is un-
necessary to take these extreme precautions, because most people,
except during sleep, take care to prevent mosquitoes from biting their face
or hands.
In houses in tropical countries the beds should be broad and long so as to leave a
good space between the sleeper and the mosquito not. The net should be hung inside
the poles and the sides and ends should nob trail on the ground, but be tucked under the
mattress. In houses where mosquito curtain poles have rot been provided it is easy
(if one has plenty of string) to arrange one's curtain properly over the bed by hanging
it from nails in the wall at each corner of the room. If a bed is so small that the
sleeper's feet or parts of his body come against the net a strip of cloth about a foot wide
should be sewn round the net just above the level of the mattress so that mosquitoes
resting on the outside of the net cannot bite the sleeper through the meshes. The net
should be stretched tightly so that air may pass freely through it. After getting into
bed one should examine the inside of the net carefully and kill any mosquito found.
Anyone who carries out the principle of always protecting himself from
mosquito bites by the simple methods outlined above, can live in the most
malarious country with impunity. There are, however, certain additional
safeguards for the individual which no wise man would neglect.
The chief of these is an application of the prophylactic method known
as the "segregation of the European " which has already been referred to,
and of course is equally applicable to any individual native who chooses
to make use of it. Remembering that this method has its origin in the obser-
vations that natives in malarious districts are the chief source of danger,
{ 86 )
and that Anopheline mosquitoes seldom fly more than half a mile, care should
be taken when camping out never to pitch one's tent within half a mile of
a native village. Travellers in Africa, as a rule, disregard this precaution
entirely, with the result that they suffer a great deal from malaria. In
India also the ddk bungalow is sometimes badly situated in the centre of a
village, and a night spent in it very frequently results in a bad attack of
malaria, unless the strictest precautions have been taken to guard against
mosquito bites.
If, for some reason or other, an individual is not able to carry out the
directions given above, he must fall back upon the plan of attempting to
ward of! malarial fevers by taking prophylactic doses of quinine, according
to one of the methods already described. For an individual who can be sure
that he will not forget to take the small close of four grains daily this plan is
probably the least inconvenient and perhaps the best for warding of! new
infections.
The prevention of relapses of former attacks.—Relapses occur only in cases
in which a former infection with malaria parasites has not been completely
cured.
They have no connection whatever with mosquitoes and may be brought
on by almost any exciting cause such as a chill, overfatigue, exposure to the
sun, etc. The best way to avoid these relapses is to go through a
course of quinine treatment similar to that which has been described under
the heading of the " disinfection of infected individuals." (Page 78.) It is
almost useless to take a dose or two of quinine occasionally, in an irregular
manner.
2. Prophylaxis for a particular body of individuals.—A person who
has learnt how to protect himself from getting an attack of malaria is quite
safe even in the most malarious surroundings ; it is of no consequence to
him whether the inhabitants of the place where he is are entirely ignorant
of prophylactic methods ; he need not attempt to exterminate Anophelines,
or to treat anyone with quinine, or to carry out any method which involves the
co-operation of other people. In many places where particular bodies of in-
dividuals such as a regiment of soldiers or the inmates of an institution, have
to live it is necessary to adopt similar methods for the prevention of malaria
among them ; we must disregard entirely th inhabitants of the place and think
( 87 )
only of the protection of the body of men under our charge. It will be
obvious, for example, that such a plan is necessary when a regiment of
soldiers is marching through a strange country, and it is equally necessary,
though perhaps less obvious, in many cantonments and stations in India.
Let us consider, for example, the case of a regiment or company of soldiers
living in one or more barracks surrounded on all sides by native bazaars
and by breeding places of Anopheline mosquitoes. Such a condition, which
is commonly met with in Indian cantonments, is illustrated below.
A. B. Barracks of the men. C. Hospital and Prison. D. Syce lines. Infection
of children 35 per cent. E. Syce lines. Infection of children 56 per cent. F. Hospital
Followers. Infection of children 60 per cent, G. Regimental bazaar. Infection of
children 40 per cent. H. H. H. Irrigation watercourse. Breeding place of Anopheline
mosquitoes.
A. and B. are the barracks of the European troops. C. is the hospital and
military prison. D. and E. are syce lines containing perhaps 200 native
children, from 40 to 60 per cent, of whom have malaria parasites in their blood.
( 88 )
F. is the hospital followers' quarters, containing perhaps 40 or 50 children, 60
per cent. of whom have malaria parasites in their blood. G. is the regimental
bazaar containing numerous children, the majority of whom are infected
with malaria parasites. All these children form a constant and abundant
source from which the numerous Anopheline mosquitoes which breed in the
irrigation watercourse (H.) and in many other watercourses near become
infected.
It will be readily seen that under these conditions the men in the
barracks must suffer severely from malaria. They are, in fact, in the midst
of an area of infected Anopheline mosquitoes, and it is difficult to understand
how, under the circumstances, any of them can escape getting malarial fever.
Assuming that in this case our prime object is to protect only the
soldiers from malaria, it is very probable that we shall attain this end more
efficiently and cheaply, and with less inconvenience to all concerned, by
adopting the principles already indicated for the individual than by any
other plan. Which of the three methods for the individual shall we adopt ?
If we decide to adopt the method of Celli we must either render the barracks
where the men sleep mosquito-proof with wire netting or we must give each man
a mosquito curtain and see that he uses it correctly. Perhaps in some Indian
stations this plan would be impracticable on account of the great heat during
the summer nights.* If so, it would be best to adopt in a modified form the
method of segregation; that is to remove the barracks or to remove the
native lines and bazaar so that the men may be at least a quarter of a mile,
and preferably half a mile, from any source of infection. It is to be noted
that as regards many cantonments in India such an expensive method as
the removal of barracks or native lines and bazaars is not essential. In the
Punjab, for example, the malarious season lasts for three or four months only,
* The malarious months of the year are not, in India, by any means the hottest months ;
as a rule the nights are cool and mosquito curtains can bo used without discomfort. It is
very probable that there are very few, if any, stations in India where soldiers (European or
Native) would object, to use mosquito curtains during the malarious months if the curtains
were issued free. At the present time many European soldiers in India provide themselves
with curtains at their own expense (aided in some cases by grants from regimental or insti-
tute funds) and use them regularly with great care. Punkahs, of course, are in general use
in the barracks of European troops during the hot weather, and they have the reputation of
keeping away mosquitoes to a slight extent, but the protection afforded by them is quite inade-
quate, and it must be remembered that in many malarious stations like Rawalpindi and
Peshawar their use has to be discontinued before the malarious season is over on account of
the cold nights.
( 89 )
and during those months the heat is not very intense, so that it would be
quite practicable for the soldiers to camp out in tents on a place which,
while being sufficiently near their area of duty, would be sufficiently far from
all sources of infection as to ensure their freedom from malaria. This plan
has been adopted recently with great success in one or two stations in
India.*
If none of the above methods could be adopted we should have to fall
back as a last resort upon prophylactic doses of quinine.
A second example of a particular body of individuals is that of the
inmates of a jail or other institution. Inmost cases such institutions are
so situated that it is not possible to deal with any conditions or with any
people outside the institution. It is usually very easy to prevent the breed-
ing of Anopheline mosquitoes within these institutions, but very difficult or
impossible to prevent the constant importation of adult Anophelines from
outside. Important difficulties also are the constant admission into the
institution of people who are infected with malaria parasites, the fact that
the population of jails is ever changing, and that many cases of malarial
fever are relapses of former infections. We must remember also that
although the methods of supervision and control of prisoners in Indian jails
are such that it would not be difficult entirely to prevent new infections by
the use of mosquito nets, the ventilation in many barracks is not good, the
floor space per prisoner is limited, and overcrowding is by no means uncom-
mon, so that in the majority of jails it would not be wise, unless ventilation
by artificial means were introduced, to use mosquito curtains. For these
reasons it may be said that as a general rule we must employ methods in which
quinine is used if we wish to reduce materially the number of cases of
malaria in jails in India. An adequate method would include in the first
place the curing of all persons who had previously suffered from malaria
and would therefore be liable to relapses, and in the second the treatment
of all inmates with prophylatic doses of quinine during the malarious season.
* For some years it has been a matter of surprise to many people that for the
prevention of malaria among European troops in India the simple measures mentioned
here have not been widely adopted. Considering the large sums of money allotted
annually for expenditure on the care and comfort of the European soldier in this
country it is especially surprising that he has not yet been provided with a mosquito
curtain and a sleeping-suit.